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gastroparesis

Failure of gastric emptying in the absence of mechanical obstruction. Etiology: 1) delayed gastric emptying (acute conditions) a) metabolic disturbances - hypokalemia - hypercalcemia - hypocalcemia - hyperglycemia* b) pharmacologic agents - tricyclic antidepressants - opioids, narcotics - anticholinergic agents - calcium channel blockers - clonidine - dopamine agonists, L-dopa - lithium carbonate - nicotine - marijuana - progesterone - octreotide - proton pump inhibitors - H2 receptor antagonists - sucralfate - IFN-alfa - beta-adrenergic agonists - glucagon - calcitonin - dexfenfluramine - diphenhydramine - fiber [3] c) pancreatitis d) surgery e) trauma f) CNS disorders g) acute gastroparesis following viral infection [3] 2) chronic gastric retention a) diabetes mellitus*, hypothyroidism & other endocrine disorders b) connective tissue disease - scleroderma c) amyloidosis d) vagotomy e) previous gastric surgery - fundoplication, bariatric surgery, pancreatic surgery f) idiopathic (viral ?) 3) other uncommon causes - Parkinson's disease - hypothyroidism - paraneoplastic syndromes (small cell lung cancer) - mesenteric ischemia [3] * 40% in type 1 diabetes, 20% in type 2 diabetes [3] * mechanical obstruction rules out gastroparesis [3] Epidemiology: - idiopathic gastroparesis is more common in women Pathology: 1) disorders of smooth muscle 2) disorders of enteric nervous system 3) disorders of central nervous system Clinical manifestations: 1) nausea/vomiting 2) GERD, hearburn 3) early satiety, post-prandial fullness 4) dyspepsia* 5) bloating & abdominal distension 6) weight loss * essentially the same disorder as functional dyspepsia [7] Laboratory: 1) complete blood count (CBC) 2) serum chemistries a) serum glucose b) serum electrolytes c) serum protein d) serum albumin e) serum calcium 3) pregnancy test 4) evaluate for secondary causes of gastroparesis a) serum TSH b) anti-nuclear antibody (ANA) c) anti-Scl-70 d) hemoglobin A1c 5) negative workup - paraneoplastic antibodies (ANNA, tTG) Special laboratory: 1) upper GI endoscopy for acute symptoms to rule out pyloric channel obstruction (1st test) [3] - retained food in the stomach is not objective evidence of gastroparesis; gastric scintigraphy needed [3] 2) capsule endoscopy (also assesses intestines) 3) biliary ultrasound if pain is a prominent feature 4) antral-duodenal manometry (clinical utility unknown) [3]) 5) electrogastrography (investigational) [3] 6) gastric emptying breath test* [3] * serum glucose in patients with diabetes mellitus should be < 275 mg/dL - hyperglycemia can impair gastric emptying Radiology: 1) plain films of abdomen, supine & upright 2) gastric scintigraphy (gastric emptying study) for chronic gastroparesis* (after upper GI endoscopy) [3] 3) upper GI series not useful [3] * serum glucose in patients with diabetes mellitus should be < 275 mg/dL - hyperglycemia can impair gastric emptying Differential diagnosis: 1) rumination syndrome 2) cyclic vomiting syndrome 3) drug adverse effect (see Etiology) 4) pregnancy 5) gastric outlet obstruction 6) small bowel obstruction - Crohn's disease 7) intestinal pseudo-obstruction 8) cannabinoid hyperemesis syndrome 9) functional dyspepsia* [3,7] * essentially the same disorder as functional dyspepsia [7] Management: 1) initial management a) correct electrolyte abnormalities b) improve glycemic control [3] - avoid GLP-1 receptor agonists (glutides), amylins (pramlintide), 2) nutritional intervention a) small, low fat meals 4-5 time per day - avoid high-fat, high fiber meals b) liquid supplement or pureed meals c) high-calorie, liquid iso-osmotic meals if indicated 3) prokinetic agents a) metoclopramide* (Reglan) up to 10 mg QID - associated with dystonia, tardive dyskinesia & parkinsonism [3] b) erythromycin 1] acutely effective, use intravenous for acute gastroparesis 2] 250 mg PO TID 3] loses effectiveness over time c) tegaserod [3] (withdrawn from US market 2007) d) cisapride (withdrawn from US market July 2000) e) domperidone (available in Canada, Mexico, Europe, but not in US) 4) anti-emetics a) metoclopramide* (Reglan) b) promethazine if adverse effects with metoclopramide [3] c) prochlorperazine (Compazine) 5) surgery - laparoscopic pyloroplasty is often done for severe gastroparesis [4] - evidence base for benefit is lacking [4] - peroral endoscopic pyloromyotomy [6] * only FDA-approved drug to treat gastroparesis [3] - associated with dystonia, tartive dyskinesia, parkinsonism

Specific

diabetic gastroparesis

General

gastric motility disorder sign/symptom

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 345
  2. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 291
  3. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  4. Toro JP et al. Efficacy of laparoscopic pyloroplasty for the treatment of gastroparesis. J Am Coll Surg 2014 Apr; 218:652 PMID: 24529808 http://www.journalacs.org/article/S1072-7515%2813%2901326-4/abstract
  5. Camilleri M, Parkman HP, Shafi MA et al Clinical guideline: management of gastroparesis. Am J Gastroenterol. 2013 Jan;108(1):18-37; PMID: 23147521
  6. Jacques J, Pagnon L, Hure F et al. Peroral endoscopic pyloromyotomy is efficacious and safe for refractory gastroparesis: Prospective trial with assessment of pyloric function. Endoscopy 2018 Jun 12. PMID: 29895073
  7. Pasricha PJ et al. Functional dyspepsia and gastroparesis in tertiary care are interchangeable syndromes with common clinical and pathologic features. Gastroenterology 2021 May; 160:2006. PMID: 33548234 https://www.gastrojournal.org/article/S0016-5085(21)00337-1/fulltext - Tack J et al. Gastroparesis: A dead-end street after all? Gastroenterology 2021 May; 160:1931. PMID: 33621562 https://www.gastrojournal.org/article/S0016-5085(21)00432-7/fulltext
  8. NEJM Knowledge+ Endocrinology
  9. Lacy BE, Cangemi DJ. Controversies in gastroparesis: discussing the sticky points. Am J Gastroenterol. 2021. PMID: 33767098
  10. Gastroparesis https://www.niddk.nih.gov/health-information/digestive-diseases/gastroparesis