Gastroparesis

Background[1]

  • Chronic GI disorder characterized by delayed gastric emptying without mechanical obstruction
  • More common in women, presumed due to elevated progesterone
  • Symptoms overlap with functional dyspepsia


Causes of Non-Obstructive Delayed Gastric Emptying

  • Idiopathic (most common)
  • Diabetes mellitus
  • Postsurgical/Vagal nerve injury
  • GI disorders associated with delayed emptying:
    • GERD, Achalasia
    • Atrophic gastritis, celiac disease
    • Functional dyspepsia
    • Hypertrophic pyloric stenosis
  • Non-GI conditions/risk factors associated with delayed gastric emptying
    • Medications: opioids, anticholinergics, PPIs, alcohol, tobacco, progesterone
    • Eating disorders: Anorexia nervosa
    • Parkinson's disease and other neurologic disorders
    • Collagen vascular disease
    • Parathyroid/thyroid disorder
    • Chronic renal insufficiency
    • Malignancy
    • Ischemic gastroparesis


Clinical Features

  • Variable symptoms
  • Early satiety, bloating, upper abdominal discomfort
  • Nausea/vomiting
  • Abdominal pain (not predominant symptom)
  • Dehydration, malnutrition if longstanding disease


Differential Diagnosis

Nausea and vomiting

Critical

Emergent

Nonemergent

Gastroparesis (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 such as Irritable Bowel Syndrome
  • Neurologic
    • Cannabinoid hyperemesis syndrome
  • Infectious
    • Spontaneous bacterial peritonitis
    • Urinary tract infection
    • Bacterial toxins, viruses (adenovirus, norovirus, rotavirus)
  • Drugs/Toxins
    • Heavy metal toxicity
    • Methanol toxicity
  • Endocrine
    • Diabetic ketoacidosis
    • Thyroid disorder
    • Parathyroid disorders
    • Uremia
  • Miscellaneous
    • Anorexia nervosa, Bulimia nervosa


Evaluation

Simple abdominal X-ray reveals a large amount of material in the stomach, suggesting severe gastric hypomotility.
  • Definitive diagnosis of gastroparesis not typically made in ED
    • Gold standard is gastric emptying scintigraphy of a solid-phase meal
    • Other studies assessing emptying: tests, upper GI barium study, ultrasound for changes in antral area
  • ED workup to exclude alternative diagnoses and complications (e.g. dehydration, Electrolyte abnormalities)
  • CBC, BMP, LFTs, lipase
  • Urinalysis, uHCG
  • Consider:
    • ECG (if >50 or at risk for cardiac disease)
    • RUQ US
    • Acute abdominal series including an upright CXR (if risk for perforated ulcer)
    • CT abdomen/pelvis to rule out obstruction
    • Upper endoscopy or radiographic upper GI series to exclude mechanical obstruction or ulcer disease


Management

ED Management

  • IVF, Electrolyte repletion
  • Antiemetics
    • Dopamine receptor antagonists: Haloperidol, Prochlorperazine, promethazine, trimethobenzamide
      • Haloperidol has been shown to reduce the rate of admission and morphine equivalent doses of analgesia[2]
    • Ondansetron
  • Prokinetic agents: enhance gut contractility
    • Metoclopramide
      • Also has antiemetic properties
      • PRN and/or standing dose prior to meals and bedtime
    • Erythromycin 125-350mg TID or QID
  • Refractory disease:
    • Nasogastric tube to decompress stomach
    • Advanced therapies (not in ED) may include: placement of jejunostomy and/or gastrostomy tube, pyloric injection of botulinum toxin, gastric electric stimulation
  • Prevention of future exacerbations:
    • Review medications, opioids, anticholinergics, PPIs may worsen or trigger symptoms
    • Avoid carbonated beverages, alcohol, and tobacco
    • Optimize glycemic control in patients with diabetes (hyperglycemia alone can delay gastric emptying)
    • Dietary: smaller but more frequent meals, minimize fat/fiber, increase liquid nutrient component


Complications

  • Acute Gastric Dilation
  • Esophagitis, Mallory-Weiss tear
  • Bezoar
  • Dehydration, malnutrition, electrolyte abnormalities


Disposition

  • Discharge with outpatient follow up unless:
    • Inability to tolerate PO
    • Need for ongoing IV rehydration, electrolyte correction, and/or glycemic control


See Also

  • Diabetes mellitus
  • Nausea/vomiting


External Links

References

  1. ↑ Parkman HP, Hasler WL, Fisher RS. American Gastroenterlogical Association technical review on the diagnosis and treatment of gastroparesis. Gastroenterology. 2004; 127(5): 1592-1622.
  2. ↑ Ramirez R, Stalcup P, Croft B, Darracq MA. Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department. Am J Emerg Med. 2017;35(8):1118-1120. doi:10.1016/j.ajem.2017.03.015
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