Gastroparesis, Diabetic Gastroparesis, Delayed Gastric Emptying

  • Definitions
  1. Gastroparesis
    1. Delayed Gastric Emptying without mechanical obstruction of the Stomach or duodenum
  • Epidemiology
  1. More common in women
  • Pathophysiology
  1. Neuromuscular dysfunction
    1. Impaired vagal tone (primary)
    2. Other factors
      1. Interstitial cells of Cajal injury
      2. Smooth Muscle dysfunction
      3. Impaired function of nerves containing nitric oxide
  2. Stomach Muscle dysfunction
    1. Stomach body and antrum with diminished contractions
    2. Stomach fundus and pylorus with disordered relaxation
  3. Gastrointestinal manifestations
    1. Decreased Stomach capacity
    2. Food contents poorly mix within the Stomach
    3. Delayed Gastric Emptying
  • Causes
  1. Diabetes Mellitus
    1. Occurs in 5% with Type I Diabetes Mellitus and 1% of Type 2 Diabetes Mellitus)
    2. Increased risk with comorbid Obesity
  2. Medications (e.g. Anticholinergic Medications, Opioids)
    1. See Medications that Delay Gastric Emptying
  3. Functional Dyspepsia
  4. Post-surgical Gastroparesis (e.g. Bariatric Surgery)
  5. Post-Viral illness (esp. Rotavirus)
  6. Neuromuscular disorders (e.g. Cerebral Palsy, Muscular Dystrophy)
  • Symptoms
  1. See Gastroparesis Cardinal Symptom Index
  2. Early symptoms
    1. Early satiety
    2. Postprandial fullness
  3. Later symptoms
    1. Nausea with peak onset after meals
    2. Vomiting of undigested food
    3. Abdominal Bloating
    4. Epigastric Pain
  • Signs
  1. Typically normal examination
  2. Epigastric tenderness
  3. Abdominal Distention
  • Complications
  1. Altered medication absorption
  2. Altered glycemic control in diabetes
    1. Delayed food absorption mismatched with an earlier Insulin release
  • Labs
  1. Standard
    1. Complete Blood Count (CBC)
    2. Thyroid Stimulating Hormone (TSH)
    3. Comprehensive metabolic panel (e.g. chem18 including Serum Glucose, Liver Function Tests)
  2. Consider when indicated
    1. Serum Lipase
    2. Urine Pregnancy Test
  • Diagnostics
  • Initial
  1. Upper endoscopy
  2. Abdominal Ultrasound (if suspected Cholelithiasis)
  • Diagnostics
  • Confirmatory
  1. Gastric emptying scintagraphy (non-invasive, preferred comfirmatory test)
    1. Scanning at 15 minute intervals for 4 hours following radiolabeled intake
    2. Positive if greater than 10% of meal retained at 4 hours
    3. May also monitor liquid emptying, but with lower Test Sensitivity
  2. Carbon 13 breath test (non-invasive)
    1. Solid meal with added carbon 13 octanoate or carbon 13 spirulina
    2. Experimental alternative to Gastric emptying scintagraphy
  3. Electrogastrography (noninvasive)
    1. Measures gastric Muscle electrical activity, monitoring electric wave abnormalities instead of gastric emptying
    2. Consider as adjunct to gastric emptying scintigraphy
  4. Wireless capsule motility
    1. Capsule transmits gastrointestinal pH, pressure and Temperature
    2. High correlation with Gastric emptying scintagraphy
  5. Antroduodenal manometry (invasive)
    1. Indicated in cases of unexplained Vomiting
  • Management
  • Approach
  1. General
    1. Consider monitoring symptoms with Gastroparesis Cardinal Symptom Index
  2. Mild Intermittent symptoms
    1. Weight and nutrition maintained with basic, non-pharmacologic measures
  3. Moderately severe symptoms, but compensated without weight loss
    1. Weight and nutrition maintained with pharmacologic management (prokinetics and Antiemetics)
  4. Gastric failure (Malnutrition refractory to medications, with frequent emergency visits)
    1. Weight and nutrition not maintained despite maximal medical therapy
    2. Continue pharmacologic management
    3. Intravenous Fluids in addition to enteral or Parenteral nutrition
    4. Upper endoscopy to exclude structural abnormalities
    5. Surgical interventions (e.g. Gastrostomy Tube) may be needed
  • Management
  • Nonpharmacologic
  1. Small, frequent meals (up to 6-8 meals per day)
  2. Liquid or semi-solid meals are preferred
  3. Decrease solid fat intake
    1. Liquid fats such as those in milk are relatively well tolerated by contrast
  4. Decrease fiber intake
    1. Associated with Delayed Gastric Emptying and risk of Bezoar formation
  5. Limit Alcohol intake
  6. Tobacco Cessation
  7. Control Blood Sugar levels in Diabetes Mellitus
    1. Keep Blood Sugars consistently less than 200 mg/dl
  8. Avoid provocative medications
    1. See Medications that Delay Gastric Emptying
  • Management
  • Pharmacologic - Prokinetics
  1. Emergency Department
    1. Haloperidol 5 mg IV or IM
      1. Growing evidence as of 2018 of benefit in the pain of Diabetic Gastroparesis as well as other causes
      2. Decreased hospitalization rate, shorter ED stay, improved pain, lower doses of Opioids
      3. Ramirez (2017) Am J Emerg Med +PMID:28320545 [PubMed]
      4. Roldan (2017) Acad Emerg Med 24(11):1307 [PubMed]
  2. First Line
    1. Metoclopramide (Reglan)
      1. Only FDA approved medication for Gastroparesis
      2. Liquid formulation is preferred for better absorption
      3. Start: 5 mg orally three times daily before meals
      4. Maximum: 10 mg orally four times daily
      5. Avoid prolonged use >12 weeks
        1. Tardive Dyskinesia risk with longterm use (also sedating)
        2. Consider stopping Metoclopramide every 12 weeks, or reducing dosage and frequency (e.g. 5 mg twice daily)
      6. Avoid the expensive intranasal formulation, Gimoti, which in 2022 approaches $1800/month (oral is $60/month)
  3. Second-line
    1. Erythromycin
      1. Dose: 250 mg orally three times daily
      2. Prokinetic via motilin receptor Agonist
      3. Side effects include Abdominal Pain and Nausea, Vomiting
      4. Efficacy decreases after fiirst 4 weeks
      5. Maganti (2003) Am J Gastroenterol 98(2): 259-63 [PubMed]
  4. Restricted use, experimental agents and methods in U.S. (may be indicated in refractory cases)
    1. Domperidone
      1. Prokinetic agent (D2 and D3 Dopamine receptor Antagonist)
      2. Not available in U.S. as of 2004 due to QTc Prolongation risk (available in some countries OTC for GERD)
      3. May be as effective as Metoclopramide, but with fewer CNS effects
      4. Adverse effects include QTc Prolongation, Arrhythmias and Light Headedness
      5. Adult Dose: 10 mg three to four times daily
      6. Patterson (1999) Am J Gastroenterol 94(5): 1230-4 [PubMed]
    2. Gastric electric stimulation (experimental)
      1. High energy, long duration pulses stimulate Stomach
      2. Complicated by gastric erosions in up to 10% of patients
      3. Chu (2012) J Gastroenterol Hepatol 27(6): 1017-26 [PubMed]
  5. Other agents previously used (listed for historical purposes)
    1. Tegaserod (Zelnorm, off U.S. market since 2007, but may still be approved case-by-case)
    2. Cisapride (off U.S. market since 2000)
    3. Bethanechol 25 mg orally four times daily
  • Management
  • Pharmacologic - Symptomatic
  1. Antiemetics
    1. Prochlorperazine (Compazine)
    2. Promethazine (Phenergan)
    3. Ondansetron (Zofran)
  2. Abdominal Pain
    1. Nortriptyline
      1. Minimally more effective than Placebo in Gastroparesis, but may be used for symptom control
      2. Anticholinergic effects may outweigh benefit
      3. May also be effective for refractory Nausea or Vomiting
  • Management
  • Refractory Cases (no ideal options)
  1. Botulinum injection to Pylorus
    1. Not effective in studies
  2. Gastrostomy Tube
    1. Venting Gastrostomy for feeding
  3. Gastrojejunostomy, pyloroplasty or gastrectomy
    1. May be indicated for severe, refractory symptoms (but with no significant studies to support as of 2016)