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Gastroparesis
From WikEM
Contents
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
Emergent
- Acute radiation syndrome
- Acute gastric dilation
- Acetaminophen toxicity
- Adrenal insufficiency
- Appendicitis
- Aspirin toxicity
- Bowel obstruction/ileus
- Carbon monoxide poisoning
- Cholecystitis
- CNS tumor
- Digoxin toxicity
- Electrolyte abnormalities
- Elevated ICP
- Gastric outlet obstruction
- Hyperemesis gravidarum
- Pancreatitis
- Peritonitis
- Ruptured viscus
- Testicular torsion/ovarian torsion
- Theophyline toxicity
Nonemergent
- Biliary colic
- Cannabinoid hyperemesis syndrome
- Chemotherapy
- Disulfiram effect
- Erythromycin
- ETOH
- Gastritis
- Gastroenteritis
- Gastroparesis
- Hepatitis
- Ibuprofen
- Labyrinthitis
- Migraine
- 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
- Infectious
- Spontaneous bacterial peritonitis
- Urinary tract infection
- Bacterial toxins, Viruses (adeno, norwalk, rota)
- Drugs/Toxins
- Endocrine
- Diabetic ketoacidosis
- Thyroid disorder
- Parathyroid disorders
- Uremia
- Miscellaneous
Evaluation
- 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: Prochlorperazine, promethazine, trimethobenzamide
- 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
- Metoclopramide
- 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 pacemaker complication|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
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.
