II. Definitions
- Gastroparesis
- Delayed Gastric Emptying without mechanical obstruction of the Stomach or duodenum
III. Epidemiology
- More common in women
IV. Pathophysiology
- Neuromuscular dysfunction
- Impaired vagal tone (primary)
- Other factors
- Interstitial cells of Cajal injury
- Smooth Muscle dysfunction
- Impaired function of nerves containing nitric oxide
- Stomach Muscle dysfunction
- Gastrointestinal manifestations
V. Causes
-
Diabetes Mellitus
- Occurs in 5% with Type I Diabetes Mellitus and 1% of Type 2 Diabetes Mellitus)
- Increased risk with comorbid Obesity
- Medications (e.g. Anticholinergic Medications, Opioids)
- Functional Dyspepsia
- Post-surgical Gastroparesis (e.g. Bariatric Surgery)
- Post-Viral illness (esp. Rotavirus)
- Neuromuscular disorders (e.g. Cerebral Palsy, Muscular Dystrophy)
VI. Symptoms
- See Gastroparesis Cardinal Symptom Index
- Early symptoms
- Early satiety
- Postprandial fullness
- Later symptoms
- Nausea with peak onset after meals
- Vomiting of undigested food
- Abdominal Bloating
- Epigastric Pain
VII. Signs
- Typically normal examination
- Epigastric tenderness
- Abdominal Distention
VIII. Complications
- Altered medication absorption
- Altered glycemic control in diabetes
- Delayed food absorption mismatched with an earlier Insulin release
IX. Differential Diagnosis
- See Vomiting Causes
- See Dyspepsia Causes
- See Epigastric Pain
- Drug-Induced Gastroparesis
- Small Bowel Obstruction
- Mechanical obstruction (e.g. malignancy)
- Cholelithiasis or Biliary Colic
- Hypothyroidism
- Pancreatitis
X. Labs
- Standard
- Complete Blood Count (CBC)
- Thyroid Stimulating Hormone (TSH)
- Comprehensive metabolic panel (e.g. chem18 including Serum Glucose, Liver Function Tests)
- Consider when indicated
XI. Diagnostics: Initial
- Upper endoscopy
- Abdominal Ultrasound (if suspected Cholelithiasis)
XII. Diagnostics: Confirmatory
- Gastric emptying scintagraphy (non-invasive, preferred comfirmatory test)
- Scanning at 15 minute intervals for 4 hours following radiolabeled intake
- Positive if greater than 10% of meal retained at 4 hours
- May also monitor liquid emptying, but with lower Test Sensitivity
- Carbon 13 breath test (non-invasive)
- Solid meal with added carbon 13 octanoate or carbon 13 spirulina
- Experimental alternative to Gastric emptying scintagraphy
- Electrogastrography (noninvasive)
- Measures gastric Muscle electrical activity, monitoring electric wave abnormalities instead of gastric emptying
- Consider as adjunct to gastric emptying scintigraphy
- Wireless capsule motility
- Capsule transmits gastrointestinal pH, pressure and Temperature
- High correlation with Gastric emptying scintagraphy
- Antroduodenal manometry (invasive)
- Indicated in cases of unexplained Vomiting
XIII. Management: Approach
-
General
- Consider monitoring symptoms with Gastroparesis Cardinal Symptom Index
- Mild Intermittent symptoms
- Weight and nutrition maintained with basic, non-pharmacologic measures
- Moderately severe symptoms, but compensated without weight loss
- Weight and nutrition maintained with pharmacologic management (prokinetics and Antiemetics)
- Gastric failure (Malnutrition refractory to medications, with frequent emergency visits)
- Weight and nutrition not maintained despite maximal medical therapy
- Continue pharmacologic management
- Intravenous Fluids in addition to enteral or Parenteral nutrition
- Upper endoscopy to exclude structural abnormalities
- Surgical interventions (e.g. Gastrostomy Tube) may be needed
XIV. Management: Nonpharmacologic
- Small, frequent meals (up to 6-8 meals per day)
- Liquid or semi-solid meals are preferred
- Decrease solid fat intake
- Liquid fats such as those in milk are relatively well tolerated by contrast
- Decrease fiber intake
- Associated with Delayed Gastric Emptying and risk of Bezoar formation
- Limit Alcohol intake
- Tobacco Cessation
- Control Blood Sugar levels in Diabetes Mellitus
- Keep Blood Sugars consistently less than 200 mg/dl
- Avoid provocative medications
XV. Management: Pharmacologic - Prokinetics
- Emergency Department
- Haloperidol 5 mg IV or IM
- Growing evidence as of 2018 of benefit in the pain of Diabetic Gastroparesis as well as other causes
- Decreased hospitalization rate, shorter ED stay, improved pain, lower doses of Opioids
- Ramirez (2017) Am J Emerg Med +PMID:28320545 [PubMed]
- Roldan (2017) Acad Emerg Med 24(11):1307 [PubMed]
- Haloperidol 5 mg IV or IM
- First Line
- Metoclopramide (Reglan)
- Only FDA approved medication for Gastroparesis
- Liquid formulation is preferred for better absorption
- Start: 5 mg orally three times daily before meals
- Maximum: 10 mg orally four times daily
- Avoid prolonged use >12 weeks
- Tardive Dyskinesia risk with longterm use (also sedating)
- Consider stopping Metoclopramide every 12 weeks, or reducing dosage and frequency (e.g. 5 mg twice daily)
- Avoid the expensive intranasal formulation, Gimoti, which in 2022 approaches $1800/month (oral is $60/month)
- Metoclopramide (Reglan)
- Second-line
- Erythromycin
- Dose: 250 mg orally three times daily
- Prokinetic via motilin receptor Agonist
- Side effects include Abdominal Pain and Nausea, Vomiting
- Efficacy decreases after fiirst 4 weeks
- Maganti (2003) Am J Gastroenterol 98(2): 259-63 [PubMed]
- Erythromycin
- Restricted use, experimental agents and methods in U.S. (may be indicated in refractory cases)
- Domperidone
- Prokinetic agent (D2 and D3 Dopamine receptor Antagonist)
- Not available in U.S. as of 2004 due to QTc Prolongation risk (available in some countries OTC for GERD)
- May be as effective as Metoclopramide, but with fewer CNS effects
- Adverse effects include QTc Prolongation, Arrhythmias and Light Headedness
- Adult Dose: 10 mg three to four times daily
- Patterson (1999) Am J Gastroenterol 94(5): 1230-4 [PubMed]
- Gastric electric stimulation (experimental)
- High energy, long duration pulses stimulate Stomach
- Complicated by gastric erosions in up to 10% of patients
- Chu (2012) J Gastroenterol Hepatol 27(6): 1017-26 [PubMed]
- Domperidone
- Other agents previously used (listed for historical purposes)
- Tegaserod (Zelnorm, off U.S. market since 2007, but may still be approved case-by-case)
- Cisapride (off U.S. market since 2000)
- Bethanechol 25 mg orally four times daily
XVI. Management: Pharmacologic - Symptomatic
- Antiemetics
-
Abdominal Pain
-
Nortriptyline
- Minimally more effective than Placebo in Gastroparesis, but may be used for symptom control
- Anticholinergic effects may outweigh benefit
- May also be effective for refractory Nausea or Vomiting
-
Nortriptyline
XVII. Management: Refractory Cases (no ideal options)
- Botulinum injection to Pylorus
- Not effective in studies
-
Gastrostomy Tube
- Venting Gastrostomy for feeding
-
Gastrojejunostomy, pyloroplasty or gastrectomy
- May be indicated for severe, refractory symptoms (but with no significant studies to support as of 2016)
XVIII. References
- (2013) Presc Lett 20(6): 34
- (2022) Presc Lett 29(10): 59
- Camilleri (2007) N Engl J Med 356:820-9 [PubMed]
- Careyva (2016) Am Fam Physician 94(12): 980-6 [PubMed]
- Parkman (2004) Gastroenterology 127:1589-91 [PubMed]
- Shakil (2008) Am Fam Physician 77(12): 1697-702 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
Definition (MSHCZE) | Porucha vyprazdňování žaludku, jeho „ochrnutí“. Vzniká při poruše nervového řízení, např. při diabetické neuropatii (gastroparesis diabeticorum). Potrava může v žaludku stagnovat až několik dnů, což narušuje i její vstřebání; při diabetu zhoršuje kompenzaci (srov. bezoár). (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ ) |
Definition (NCI_CTCAE) | A disorder characterized by an incomplete paralysis of the muscles of the stomach wall resulting in delayed emptying of the gastric contents into the small intestine. |
Definition (NCI) | Paralysis of the muscles of the stomach wall resulting in delayed emptying of the gastric contents into the small intestine. |
Definition (MSH) | Chronic delayed gastric emptying. Gastroparesis may be caused by motor dysfunction or paralysis of STOMACH muscles or may be associated with other systemic diseases such as DIABETES MELLITUS. |
Concepts | Disease or Syndrome (T047) |
MSH | D018589 |
ICD9 | 536.3 |
ICD10 | K31.84 |
SnomedCT | 77164002, 235675006, 196753007 |
English | GASTROPARESIS, GASTRIC ATONY, Gastric Stases, Gastric Stasis, Gastropareses, Stases, Gastric, Stasis, Gastric, gastroparesis (diagnosis), gastroparesis, Atony of stomach, Atony stomach, Stomach atony, Paralysis gastric, Gastroparesis [Disease/Finding], delayed gastric emptying, gastric paralysis, gastric atony, gastropareses, Gastroparesis, Gastroparalysis, Gastroparesis syndrome (disorder), Gastric atony, Gastric stasis, Gastric atonia, Gastric atonia (disorder), Gastroparesis (disorder), Gastroparesis syndrome, atony; stomach, paralysis; stomach, stomach; paralysis, Gastroparesis syndrome, NOS, Gastroparesis syndrome (disorder) [Ambiguous], Stasis;gastric, gastric stasis |
German | GASTROPARESE, Atonie des Magens, Laehmung, Magen, Magenstase, MAGENATONIE, Magenatonie, Gastroparese, Gastraler Rückstau |
Portuguese | GASTROPARESIA, Paralisia gástrica, Atonia do estômago, Estase gástrica, ATONIA GASTRICA, Atonia gástrica, Estase Gástrica, Gastroparesia |
Italian | Atonia gastrica, Paralisi gastrica, Atonia dello stomaco, Stasi gastrica, Gastroparesi |
Dutch | gastroparese, maagstase, atonie van de maag, atonie maag, maagparalyse, atonie; maag, maag; paralyse, paralyse; maag, maagatonie, Gastroparalyse, Gastroparese, Maagverlamming |
French | Atonie de l'estomac, Paralysie gastrique, Atonie stomacale, ATONIE GASTRIQUE, GASTROPARESIE, Atonie gastrique, Gastroparésie, Stase gastrique |
Spanish | Atonía de estómago, Estasis gástrica, Parálisis gástrica, GASTRICA, ATONIA, GASTROPARESIA, Gastroparesia, estasis gástrica, síndrome de gastroparesia (trastorno), Gastroparesis, atonía gástrica (trastorno), atonía gástrica, gastroparesia (trastorno), gastroparesia, síndrome de gastroparesia (concepto no activo), síndrome de gastroparesia, Atonía gástrica, estasis gástrico, Estasis Gástrica |
Japanese | 胃アトニー, 胃内容うっ滞, 胃麻痺, イマヒ, イナイヨウウッタイ, イアトニー, イフゼンマヒ, 胃のうっ滞, 軽症胃アトニー, 胃不全麻痺 |
Swedish | Magmuskelförlamning |
Czech | žaludek - paréza, gastroparéza, Gastroparéza, Paralýza žaludku, Atonie žaludku, Žaludeční stáza, Žaludeční atonie |
Finnish | Gastropareesi |
Russian | GASTROPAREZ, ZHELUDOCHNYI STAZ, ГАСТРОПАРЕЗ, ЖЕЛУДОЧНЫЙ СТАЗ |
Polish | Gastroplegia, Niedowład żołądka, Zastój żołądkowy, Porażenie żołądka |
Hungarian | Gyomoratonia, Gyomor paralysis, Gyomor atónia, Gastroparesis, Gyomor atonia, Gyomor atoniája, Gyomor stasis |
Norwegian | Gastroparese |
Ontology: Diabetic gastroparesis (C0267176)
Concepts | Disease or Syndrome (T047) |
SnomedCT | 34140002 |
Italian | Gastroparesi diabetica |
Czech | Diabetická gastroparéza |
Japanese | 糖尿病性胃不全麻痺, トウニョウビョウセイイフゼンマヒ |
English | diabetic gastroparesis, Diabetic gastroparesis, Diabetic gastroparesis (disorder) |
Hungarian | Diabeteses gastroparesis |
Spanish | gastroparesia diabética (trastorno), gastroparesia diabética, Gastroparesia diabética |
Portuguese | Gastroparese diabética |
Dutch | diabetische gastroparese |
French | Gastroparésie diabétique |
German | Diabetische Gastroparese |
Ontology: Delayed gastric emptying (C0740411)
Concepts | Finding (T033) |
SnomedCT | 314944001 |
English | Delayed gastric emptying, delayed gastric emptying, delay emptying gastric, delayed empty gastric, Delayed gastric emptying (disorder) |
Dutch | vertraagde maaglediging |
French | Vidage gastrique retardé |
German | verzoegerte Magenentleerung |
Italian | Svuotamento gastrico ritardato |
Portuguese | Esvaziamento gástrico retardado |
Spanish | Vaciamiento gástrico retardado, vaciamiento gástrico tardío (trastorno), vaciamiento gástrico tardío |
Japanese | 胃排出遅延, イハイシュツチエン |
Czech | Opožděné vyprazdňování žaludku |
Hungarian | Késői gyomor ürülés |