Gastroparesis

Background

• 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

• ACS/MI
• Boerhaave's
• DKA
• Intracranial hemorrhage
• Ischemic bowel
• Meningitis
• Sepsis

Emergent

• Acute radiation syndrome
• Acute gastric dilation
• Adrenal insufficiency
• Appendicitis
• Bowel obstruction/ileus
• Carbon monoxide poisoning
• Cholecystitis
• CNS tumor
• Electrolyte abnormalities
• Elevated ICP
• Gastric outlet obstruction, gastric volvulus
• Hyperemesis gravidarum
• Medication related
  • Acetaminophen toxicity
  • Aspirin toxicity
  • Digoxin toxicity
  • Theophylline toxicity
  • GLP-1 receptor agonist toxicity
• Pancreatitis
• Peritonitis
• Ruptured viscus
• Testicular torsion/ovarian torsion

Nonemergent

• Acute gastroenteritis
• Biliary colic
• Cannabinoid hyperemesis syndrome
• Chemotherapy
• Cyclic vomiting syndrome
• ETOH
• Gastritis
• Gastroenteritis
• Gastroparesis
• Hepatitis
• Labyrinthitis
• Migraine
• Medication related
  • Disulfiram effect
  • Erythromycin
  • Ibuprofen
  • Ipecac toxicity
• Motion sickness
• Narcotic withdrawal
• Thyroid
• Pregnancy
• Peptic ulcer disease
• Renal colic
• UTI

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
  • 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