Gastroparesis

Background

• Symptomatic chronic stomach disorder characterized by delayed gastric emptying without mechanical obstruction
• More common in women, presumed due to elevated progesterone
• Disease associated with reduced quality of life
• Most commonly seen in diabetics, but other etiologies listed below

Causes of Non-Obstructive Delayed Gastric Emptying

• Idiopathic
• Diabetes mellitus
• Postsurgical/Vagal nerve injury
• GI disorders associated with delated gastric emptying
  • GERD
  • Achalasia
  • Atrophic gastritis
  • Functional dyspepsia
  • Hypertrophic Pyloric stenosis
  • Celiac disease
• Non-GI disorders associated with delayed gastric emptying
  • Eating disorders: Anorexia nervosa
  • Neurologic disorders such as parkinson's
  • Collagen vascular disorders
  • Endocrine and metabolic disorders
    • Thyroid/Parathyroid dysfunction
    • Chronic renal insufficiency
  • Medication associated
    • Most commonly used: Opioid analgesics, anticholinergics, progesterone, PPIs, alcohol, tobacco

Clinical Features

• Symptons variable and include:
  • Early satiety
  • Nausea and vomiting
  • Bloating and upper abdominal discomfort
  • Abdominal pain (not predominant symptom)
• Signs, long standing disease:
  • Dehydration
  • Malnourishment
• Functional dyspepsia- abdominal pain is the predominant symptom

Differential Diagnosis

By organ system

GI

• Peptic ulcer disease
• Mechanical Obstruction
  • Adhesion
  • Small bowel obstruction/LBO
  • Gastric outlet obstruction/Pyloric stenosis
  • Volvulus
  • Strangulated hernia
• Pancreatitis
• Appendicitis
• Cholecystitis
• Cholangitis
• Acute Hepatitis
• IBD
• Intussusception
• Malignancy
• Mesenteric ischemia
• Esophageal disorders (e.g. achalasia, GERD, esophagitis)
• Functional disorders
  • Psychogenic
  • IBS

Neurologic

• Cannabinoid hyperemesis syndrome

Infectious

• Bacterial toxins
• SBP
• UTI
• Viruses (adeno, norwalk, rota

Drugs/Toxins

• Heavy metal poisoning
• Methanol poisoning

Endocrine

• DKA
• Thyroid/parathyroid disorders
• Uremia

Miscellaneous

• Anorexia/bulimia

Evaluation

• Diagnosed by demonstrating delayed gastric emptying in a symptomatic patient after other etiologies are excluded
  • Gold standard to evaluate for delayed gastric emptying:
    • Gastric emptying scintigraphy of a solid-phase meal
      • Test quantifies the emptying of a physiologic caloric meal (0, 1, 2, and 4 hours post-prandial measurements)
  • Alternative tests assessing gastric emptying include:
    • Breath tests
    • Upper GI barium study
    • Ultrasound for serial changes in antral area
  • Abnormal gastric emptying suggests but does not prove that symptoms are caused by Gastroparesis

• • • • Disorder of gastric motor function not excluded in patients with normal gastric emptying
        • Regional dysfunctions of the stomach such as impaired fundic relaxation or gastric myoelectric dysrhythmias
    • Screen for secondary causes of Gastroparesis
      • Thyroid function tests
      • Rheumatologic serologies
      • HbA1C

Workup To Exclude Alternative Etiologies

• CBC
• Chem
• LFTs
• Lipase
• Coags
• Urinalysis
• Urine pregnancy (females)
• ?ECG (if >50 or at risk for cardiac disease)
• ?RUQ US
• ?Acute abdominal series including an upright CXR
  • Consider if at risk for perforated ulcer
• Upper endoscopy or radiographic upper GI series to exclude mechanical obstruction or ulcer disease
• Consider CT with oral and/or IV contrast to assess for intestinal obstruction

Complications

• Acute Gatstric Dilation
• Esophagitis
• Mallory Weiss Tear
• Bezoar
• Dehydration
• Malnutrition