Source: Camilleri M, Parkman H, Shafi M, Abell T, Gerson L. Clinical guideline: management of gastroparesis. Am J Gastroenterol. 2013; 108 – 37.
Definition
- Combination of symptoms of gastroparesis, absence of gastric outlet obstruction or ulceration, and delay in gastric emptying
- Cardinal symptoms: Early satiety, post-prandial fullness, nausea, vomiting, bloating, and upper abdo pain
- Accelerated gastric emptying and functional dyspepsia can present with similar symptoms – thus, documentation of delayed gastric emptying recommended before selecting therapy with prokinetic agents or gastric electrical stimulation (GES)
Epidemiology
- Prevalence in community ~ 5% among type 1 diabetics and 1% among type 2 diabetics, and 0.2% of controls
Identifying the Cause
- Screen for presence of diabetes, thyroid dysfunction, neurological disease, prior gastric or bariatric surgery, and autoimmune disorders
- In a tertiary referral setting, aetiology is 29% diabetic, 13% post-surgical, and 36% idiopathic
- Post-surgical: recognized complication of fundoplication (possibly from vagal injury during surgery)
- Should ask about prior acute illness suggestive of viral infection (post-viral gastroparesis)
- Markedly uncontrolled glucose levels may aggravate symptoms of gastroparesis and delay gastric emptying
- Medication induced delay in gastric emptying, esp. from narcotic and anti-cholinergic agents and GLP-1 and amylin analogs among diabetics, cyclosporine should be considered
- Gastroparesis can be associated with and may aggravate GORD
- Other rare causes:
- Diseases affecting extrinsic neural control, e.g. Parkinsonism, amyloidosis, paraneoplastic disease
- Disorders that result in infiltration or degeneration of the muscle layer of the stomach, e.g. Scleroderma
- Mesenteric ischaemia
Diagnosis of Gastroparesis
- Documented delayed gastric emptying required
- Scintigraphic gastric emptying of solids is the standard
- Most reliable method and parameter is gastric retention of solids at 4 hours
- Other approaches: wireless capsule motility testing, and 13C breath testing – further validation required
- Meds affecting gastric emptying should be stopped at least 48 hrs before
- Pts with diabetes should have blood glucose measured before starting the gastric emptying test – hyperglycaemia treated first and then start test once glucose < 275 mg/dl (~ 15 mmol/L)
Differential Diagnosis
- Presence of rumination syndrome and/or eating disorders, e.g. anorexia nervosa and bulimia, should be considered These disorders may be associated with delayed gastric emptying
- Cyclic vomiting syndrome – defined as recurrent episodic episodes of nausea and vomiting, should also be considered
- Chronic usage of cannabinoid agents may cause a syndrome similar to cyclic vomiting syndrome
Management of Gastroparesis
- First line: Restoration of fluids and electrolytes, nutritional support, and glycaemic control in diabetics
- Frequent small volume nutrient meals low in fat and soluble fibre (fat and fibre tend to delay gastric emptying)
- If oral route insufficient, enteral alimentation by jejunostomy tube feeding should be pursued (after a trial of nasoenteric tube feeding)
- Indications for enteral nutrition: unintentional weight loss 10% or more of usual body weight during a period of 3-6 months and/or repeated hospitalizations for refractory symptoms
- Post-pyloric feeding preferable to gastric feeding
- Enteral feeding preferable to parenteral nutrition
- Other lifestyle mgmt: Avoid carbonated drinks, alcohol and smoking
Pharmacologic Therapy
- Prokinetics – Metoclopramide first line – use in liquid formation
- Risk of Tardive Dyskinesia < 1% - Pts should be advised to cease medication if they develop side effects, e.g. involuntary movements
- Start at 5mg TDS before meals and maximum dose of 40mg/day
- Alternative: Domperidone
- Be aware of potential QT interval prolongation – baseline ECG recommended and withhold treatment if QTc > 470 ms in male and 450 ms in female
- Start at 10mg TDS and increase to 20mg TDS and at bedtime
- Others: Erythromycin – limited by long term tachyphylaxis
- Anti-emetics – improves n/v but no impact on gastric emptying
- Tricyclic antidepressants can be considered for refractory nausea and vomiting but will not improve and may even slow gastric emptying
- Nortriptyline has lower incidence of anticholinergic side effects than amitriptyline
Gastric Electrical Stimulation
- GES may be considered for compassionate treatment in pts with refractory symptoms, esp. nausea and vomiting
- Symptom severity and gastric emptying been shown to improve in pts with diabetic gastroparesis but not in idiopathic or post-surgical pts
Surgical Treatments
- Venting Gastrostomy, Gastrojejunostomy, Pyloroplasty and Gastrectomy
- Gastrostomy for venting and/or jejunostomy for feeding may be performed for symptom relief
- Completion gastrectomy could be considered in post-surgical gastroparesis pts who remain markedly symptomatic and fail medical therapy
- Surgical pyloroplasty or gastrojejunostomy has been performed for treatment for refractory gastroparesis – but – further studies needed before advocating this treatment
- Partial gastrectomy and pyloroplasty should be used rarely, only in carefully selected pts
Complementary and Alternative Medicines
- Acupuncture can be considered as an alternative therapy – associated with improved rates of gastric emptying and reduction of symptoms