Gastroparesis: Difference between revisions
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==Background==
<languages/>
*Symptomatic chronic stomach disorder characterized by delayed gastric emptying without mechanical obstruction  
<translate>
 
==Background<ref>Parkman HP, Hasler WL, Fisher RS. American Gastroenterlogical Association technical review on the diagnosis and treatment of gastroparesis. Gastroenterology. 2004; 127(5): 1592-1622.</ref>==
 
*Chronic GI disorder characterized by delayed gastric emptying ''without'' mechanical obstruction  
*More common in women, presumed due to elevated progesterone
*More common in women, presumed due to elevated progesterone
*Disease associated with reduced quality of life
*Symptoms overlap with functional dyspepsia
*Most commonly idiopathic but also commonly seen in diabetics
 
*Symptoms overlap with [[Functional Dyspepsia]]


==Causes of Non-Obstructive Delayed Gastric Emptying==
===Causes of Non-Obstructive Delayed Gastric Emptying===
*Idiopathic
 
*[[Diabetes mellitus]]
*Idiopathic (most common)
*[[Special:MyLanguage/Diabetes mellitus|Diabetes mellitus]]
*Postsurgical/Vagal nerve injury  
*Postsurgical/Vagal nerve injury  
*GI disorders associated with delated gastric emptying
*GI disorders associated with delayed emptying:
**[[GERD]]
**[[Special:MyLanguage/GERD|GERD]], [[Special:MyLanguage/Achalasia|Achalasia]]
**[[Achalasia]]
**Atrophic [[Special:MyLanguage/gastritis|gastritis]], celiac disease
**Atrophic gastritis
**Functional [[Special:MyLanguage/dyspepsia|dyspepsia]]
**[[Functional Dyspepsia]]
**Hypertrophic [[Special:MyLanguage/pyloric stenosis|pyloric stenosis]]
**Hypertrophic [[Pyloric stenosis]]
*Non-GI conditions/risk factors associated with delayed gastric emptying
**Celiac disease
**Medications: [[Special:MyLanguage/opioids|opioids]], [[Special:MyLanguage/anticholinergics|anticholinergics]], [[Special:MyLanguage/PPI|PPI]]s, [[Special:MyLanguage/alcohol|alcohol]], tobacco, progesterone
*Non-GI disorders associated with delayed gastric emptying
**Eating disorders: [[Special:MyLanguage/Anorexia nervosa|Anorexia nervosa]]
**Eating disorders: [[Anorexia nervosa]]
**[[Special:MyLanguage/Parkinson's disease|Parkinson's disease]] and other neurologic disorders
**Neurologic disorders such as parkinson's  
**[[Special:MyLanguage/Collagen vascular disease|Collagen vascular disease]]
**Collagen vascular disorders
**Parathyroid/[[Special:MyLanguage/thyroid disorder|thyroid disorder]]
**Endocrine and metabolic disorders
**Chronic renal insufficiency  
***Thyroid/Parathyroid dysfunction
**Malignancy
***Chronic renal insufficiency  
**Medication associated
***Most commonly used: Opioid analgesics, anticholinergics, progesterone, PPIs, alcohol, tobacco
**Malignancy associated
**Ischemic gastroparesis
**Ischemic gastroparesis


==Clinical Features==
==Clinical Features==
*Symptons variable and include:
 
**Early satiety  
*Variable symptoms
**Nausea and vomiting
*Early satiety, bloating, upper abdominal discomfort
**Bloating and upper abdominal discomfort
*[[Special:MyLanguage/Nausea/vomiting|Nausea/vomiting]]
**Abdominal pain (not predominant symptom)
*[[Special:MyLanguage/Abdominal pain|Abdominal pain]] (''not'' predominant symptom)
*Signs, long standing disease:
*[[Special:MyLanguage/Dehydration|Dehydration]], [[Special:MyLanguage/malnutrition|malnutrition]] if longstanding disease
**Dehydration
 
**Malnourishment


==Differential Diagnosis==
==Differential Diagnosis==
===By organ system===
 
</translate>
{{Nausea and vomiting DDX}}
<translate>
 
===Gastroparesis (by organ system)===
 
*GI
*GI
**[[Peptic ulcer disease]]
**[[Special:MyLanguage/Peptic ulcer disease|Peptic ulcer disease]]
**Mechanical Obstruction
**Mechanical Obstruction
***Adhesion
***Adhesion
***[[Small bowel obstruction]]/LBO
***[[Special:MyLanguage/Small bowel obstruction|Small bowel obstruction]]/LBO
***Gastric outlet obstruction/[[Pyloric stenosis]]
***Gastric outlet obstruction/[[Special:MyLanguage/Pyloric stenosis|Pyloric stenosis]]
***[[Volvulus]]
***[[Special:MyLanguage/Volvulus|Volvulus]]
***Strangulated hernia
***Strangulated [[Special:MyLanguage/hernia|hernia]]
**[[Pancreatitis]]
**[[Special:MyLanguage/Pancreatitis|Pancreatitis]]
**[[Appendicitis]]
**[[Special:MyLanguage/Appendicitis|Appendicitis]]
**[[Cholecystitis]], [[Cholangitis]]
**[[Special:MyLanguage/Cholecystitis|Cholecystitis]], [[Special:MyLanguage/Cholangitis|Cholangitis]]
**[[Acute Hepatitis]]
**[[Special:MyLanguage/Acute Hepatitis|Acute Hepatitis]]
**[[IBD]
**[[Special:MyLanguage/IBD|IBD]]
**[[Intussusception]]
**[[Special:MyLanguage/Intussusception|Intussusception]]
**Malignancy  
**Malignancy  
**[[Mesenteric ischemia]]
**[[Special:MyLanguage/Mesenteric ischemia|Mesenteric ischemia]]
**Esophageal disorders (e.g. achalasia, GERD, [[esophagitis]])
**Esophageal disorders (e.g. [[Special:MyLanguage/achalasia|achalasia]], [[Special:MyLanguage/GERD|GERD]], [[Special:MyLanguage/esophagitis|esophagitis]])
**Functional disorders such as [[Irritable Bowel Syndrome]]
**Functional disorders such as [[Special:MyLanguage/Irritable Bowel Syndrome|Irritable Bowel Syndrome]]
*Neurologic
*Neurologic
**[[Cannabinoid hyperemesis syndrome]]
**[[Special:MyLanguage/Cannabinoid hyperemesis syndrome|Cannabinoid hyperemesis syndrome]]
*Infectious
*Infectious
**[[Spontaneous bacterial peritonitis]]
**[[Special:MyLanguage/Spontaneous bacterial peritonitis|Spontaneous bacterial peritonitis]]
**[[Urinary tract infection]]
**[[Special:MyLanguage/Urinary tract infection|Urinary tract infection]]
**Bacterial toxins, Viruses (adeno, norwalk, rota)
**[[Special:MyLanguage/bacterial disease|Bacterial]] toxins, [[Special:MyLanguage/viruses|viruses]] ([[Special:MyLanguage/adenovirus|adenovirus]], [[Special:MyLanguage/norovirus|norovirus]], [[Special:MyLanguage/rotavirus|rotavirus]])
*Drugs/Toxins
*Drugs/Toxins
**Heavy metal poisoning
**[[Special:MyLanguage/Heavy metal toxicity|Heavy metal toxicity]]
**Methanol poisoning
**[[Special:MyLanguage/Methanol toxicity|Methanol toxicity]]
*Endocrine
*Endocrine
**[[Diabetic ketoacidosis]]
**[[Special:MyLanguage/Diabetic ketoacidosis|Diabetic ketoacidosis]]
**Thyroid/parathyroid disorders
**[[Special:MyLanguage/Thyroid disorder|Thyroid disorder]]
**[[Uremia]]
**Parathyroid disorders
**[[Special:MyLanguage/Uremia|Uremia]]
*Miscellaneous
*Miscellaneous
**[[Anorexia nervosa]], [[Bulimia nervosa]]
**[[Special:MyLanguage/Anorexia nervosa|Anorexia nervosa]], [[Special:MyLanguage/Bulimia nervosa|Bulimia nervosa]]
 


==Evaluation==
==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
[[File:GastroparesisXray.jpg|thumb|Simple abdominal X-ray reveals a large amount of material in the stomach, suggesting severe gastric hypomotility.]]
*****Regional dysfunctions of the stomach such as impaired fundic relaxation or gastric myoelectric dysrhythmias
*Definitive diagnosis of gastroparesis not typically made in ED
***Screen for secondary causes of [[Gastroparesis]]
**Gold standard is gastric emptying scintigraphy of a solid-phase meal
****Thyroid function tests
**Other studies assessing emptying: tests, upper GI barium study, ultrasound for changes in antral area
****Rheumatologic serologies
*ED workup to exclude alternative diagnoses and complications (e.g. [[Special:MyLanguage/dehydration|dehydration]], [[Special:MyLanguage/Electrolyte abnormalities|Electrolyte abnormalities]])
****HbA1C
*CBC, BMP, [[Special:MyLanguage/LFTs|LFTs]], lipase
*[[Special:MyLanguage/Urinalysis|Urinalysis]], uHCG
*Consider:
**[[Special:MyLanguage/ECG|ECG]] (if >50 or at risk for cardiac disease)
**[[Special:MyLanguage/RUQ US|RUQ US]]
**[[Special:MyLanguage/Acute abdominal series|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


===Workup To Exclude Alternative Etiologies===
*CBC
*Chem
*LFTs
*Lipase
*Coags
*[[Urinalysis]]
*Urine pregnancy (females)
*Consider:
**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
**CT with oral and/or IV contrast to assess for intestinal obstruction


==Treatment of Symptomatic [[Gastroparesis]]==
==Management==
*General principles include
 
**1. Correct fluid, electrolye, and nutritional deficiencies
 
**2. Identify and treat underlying cause if possible
===ED Management===
**3. Reduce symptoms
 
*Important to review patient's medications, some medication may exacerbate symptoms
*[[Special:MyLanguage/IVF|IVF]], [[Special:MyLanguage/Electrolyte repletion|Electrolyte repletion]]
*Diabetic patient should have optimal glucose control
*[[Special:MyLanguage/Antiemetics|Antiemetics]]
**[[Hyperglycemia]] alone can delay gastric emptying
**Dopamine receptor antagonists: [[Special:MyLanguage/Haloperidol|Haloperidol]], [[Special:MyLanguage/Prochlorperazine|Prochlorperazine]], [[Special:MyLanguage/promethazine|promethazine]], trimethobenzamide
*Dietary modifications
***[[Special:MyLanguage/Haloperidol|Haloperidol]] has been shown to reduce the rate of admission and morphine equivalent doses of analgesia<ref>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</ref>
**Increase liquid nutrient component
**[[Special:MyLanguage/Ondansetron|Ondansetron]]
**Minimize fat and fiber
*Prokinetic agents: enhance gut contractility
**Smaller but more frequent meals
**[[Special:MyLanguage/Metoclopramide|Metoclopramide]]  
**Avoid carbonated beverages, [[alcohol]], and [[tobacco]]
***Also has antiemetic properties
*Medications:
***PRN and/or standing dose prior to meals and bedtime
**Anti-emetic agent- typical primary therapy
**[[Special:MyLanguage/Erythromycin|Erythromycin]] 125-350mg TID or QID
***Phenothiazines (dopamine receptor antagonists)
*Refractory disease:
****[[Prochlorperazine]]
**[[Special:MyLanguage/Nasogastric tube|Nasogastric tube]] to decompress stomach
****Trimethobenzamide
**Advanced therapies (not in ED) may include: placement of jejunostomy and/or [[Special:MyLanguage/G-tube complications|gastrostomy tube]], pyloric injection of botulinum toxin, [[Special:MyLanguage/Gastric pacemaker complication|gastric electric stimulation]]
****[[Promethazine]]
*Prevention of future exacerbations:
***Serotonin receptor antagonists
**Review medications,  [[Special:MyLanguage/opioids|opioids]], [[Special:MyLanguage/anticholinergics|anticholinergics]], [[Special:MyLanguage/PPI|PPI]]s may worsen or trigger symptoms
***[[Ondansetron]]
**Avoid carbonated beverages, [[Special:MyLanguage/alcohol|alcohol]], and [[Special:MyLanguage/tobacco|tobacco]]
***Typically only used prn
**Optimize glycemic control in patients with [[Special:MyLanguage/diabetes|diabetes]] ([[Special:MyLanguage/hyperglycemia|hyperglycemia]] alone can delay gastric emptying)
**Prokinetic agent
**Dietary: smaller but more frequent meals, minimize fat/fiber, increase liquid nutrient component
***Enhance gut contractility
 
***[[Metoclopramide]]
****Also anti-emetic actions
****Limited use to approximately 1 month
****Starting dose 10mg 30 minutes before meals and at bedtime
***[[Erythromycin]]
****Macrolide antibiotic has pro kinetic actions
****Starting dose 125-350mg TID or QID
****Similar efficacy as [[Metoclopramide]]
***Other agents less commonly used
*Refractory disease
**Nasogastric suction to decompress the stomach
**Some patients respond better to alternative pro-kinetics than others
**Dual therapy with both anti-emetic and pro-kinetic agents
***Consider psychotropic medications
**Placement of feeding jejunostomy and/or venting gastrostomy
**Advanced/experimental therapies include:  
***Pyloric infection of botulinum toxin
***Gastric electric stimulation
***Alternative and unconventional medical therapies


==Complications==
==Complications==
*[[Acute Gastric Dilation]]
 
*[[Esophagitis]]
*[[Special:MyLanguage/Acute Gastric Dilation|Acute Gastric Dilation]]
*[[Mallory-Weiss tear]]
*[[Special:MyLanguage/Esophagitis|Esophagitis]], [[Special:MyLanguage/Mallory-Weiss tear|Mallory-Weiss tear]]
*[[Bezoar]]
*[[Special:MyLanguage/Bezoar|Bezoar]]
*Dehydration
*[[Special:MyLanguage/Dehydration|Dehydration]], [[Special:MyLanguage/malnutrition|malnutrition]], [[Special:MyLanguage/electrolyte abnormalities|electrolyte abnormalities]]
*Malnutrition
 


==Disposition==
==Disposition==
*Refractory disease may require hospitalization if:  
 
**PO intolerance
*Discharge with outpatient follow up unless:
**Pronounced dehydration requiring intravenous hydration
**Inability to tolerate PO
**Glycemic control
**Need for ongoing IV rehydration, electrolyte correction, and/or glycemic control
**Electrolyte correction
 
*Outpatient management if none of the above and symptoms controlled


==See Also==
==See Also==
*[[Diabetes mellitus]]
 
*[[Special:MyLanguage/Diabetes mellitus|Diabetes mellitus]]
*[[Special:MyLanguage/Nausea/vomiting|Nausea/vomiting]]
 


==External Links==
==External Links==


==References==
==References==
<references/>
<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.
 
 
[[Category:GI]]
</translate>

Latest revision as of 22:56, 4 January 2026


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


Clinical Features


Differential Diagnosis

Nausea and vomiting

Critical

Emergent

Nonemergent

Gastroparesis (by organ system)


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


Complications


Disposition

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


See Also


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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