II. Definition

  1. Delayed Gastric Emptying without mechanical obstruction of the Stomach or duodenum

III. Epidemiology

  1. More common in women

IV. 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

V. 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
    1. See Medications that Delay Gastric Emptying
  3. Functional Dyspepsia
  4. Post-surgical Gastroparesis (e.g. Bariatric Surgery)

VI. 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. Abdominal Pain

VII. Signs

  1. Typically normal examination
  2. Epigastric tenderness
  3. Abdominal distention

VIII. Complications

  1. Altered medication absorption
  2. Altered glycemic control in diabetes
    1. Delayed food absorption mismatched with an earlier Insulin release

X. 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

XI. Diagnostics: Initial

  1. Upper endoscopy
  2. Abdominal Ultrasound (if suspected Cholelithiasis)

XII. 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

XIII. 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

XIV. 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

XV. Management: Pharmacologic - Prokinetics

  1. Emergency Department
    1. Haloperidol 5 mg IM
      1. Observational study for Diabetic Gastroparesis patients presenting with acute pain
      2. Decreased hospitalization rate and resulted in lower doses of Opioids administered
      3. Ramirez (2017) Am J Emerg Med +PMID:28320545 [PubMed]
  2. First Line
    1. Metoclopramide (Reglan)
      1. Liquid formulation is preferred for better absorption
      2. Start: 5 mg orally three times daily before meals
      3. Maximum: 10 mg orally four times daily
      4. Tardive Dyskinesia risk with longterm use (also sedating)
      5. Only FDA approved medication for Gastroparesis
  3. Second-line
    1. Erythromycin 250 mg orally three times daily
      1. Prokinetic via motilin receptor agonist
      2. Side effects include Abdominal Pain and Nausea, Vomiting
      3. Efficacy decreases after fiirst 4 weeks
      4. 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. May be as effective as reglan, but with fewer CNS effects
      3. Side effects include arrhythmias and light headedness
      4. Dose: 10 mg three to four times daily
      5. 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

XVI. 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

XVII. 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)

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Ontology: Gastroparesis (C0152020)

Definition (MSHCZE) Porucha vyprazdňování žaludku, jeho „ochrnutí“. Vzniká při poruše nervového řízení, např. při diabetické neuropatii (gastroparesis diabeticorum). Potrava může v žaludku stagnovat až několik dnů, což narušuje i její vstřebání; při diabetu zhoršuje kompenzaci (srov. bezoár). (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (NCI_CTCAE) A disorder characterized by an incomplete paralysis of the muscles of the stomach wall resulting in delayed emptying of the gastric contents into the small intestine.
Definition (NCI) Paralysis of the muscles of the stomach wall resulting in delayed emptying of the gastric contents into the small intestine.
Definition (MSH) Chronic delayed gastric emptying. Gastroparesis may be caused by motor dysfunction or paralysis of STOMACH muscles or may be associated with other systemic diseases such as DIABETES MELLITUS.
Concepts Disease or Syndrome (T047)
MSH D018589
ICD9 536.3
ICD10 K31.84
SnomedCT 77164002, 235675006, 196753007
English GASTROPARESIS, GASTRIC ATONY, Gastric Stases, Gastric Stasis, Gastropareses, Stases, Gastric, Stasis, Gastric, gastroparesis (diagnosis), gastroparesis, Atony of stomach, Atony stomach, Stomach atony, Paralysis gastric, Gastroparesis [Disease/Finding], delayed gastric emptying, gastric paralysis, gastric atony, gastropareses, Gastroparesis, Gastroparalysis, Gastroparesis syndrome (disorder), Gastric atony, Gastric stasis, Gastric atonia, Gastric atonia (disorder), Gastroparesis (disorder), Gastroparesis syndrome, atony; stomach, paralysis; stomach, stomach; paralysis, Gastroparesis syndrome, NOS, Gastroparesis syndrome (disorder) [Ambiguous], Stasis;gastric, gastric stasis
German GASTROPARESE, Atonie des Magens, Laehmung, Magen, Magenstase, MAGENATONIE, Magenatonie, Gastroparese, Gastraler Rückstau
Portuguese GASTROPARESIA, Paralisia gástrica, Atonia do estômago, Estase gástrica, ATONIA GASTRICA, Atonia gástrica, Estase Gástrica, Gastroparesia
Italian Atonia gastrica, Paralisi gastrica, Atonia dello stomaco, Stasi gastrica, Gastroparesi
Dutch gastroparese, maagstase, atonie van de maag, atonie maag, maagparalyse, atonie; maag, maag; paralyse, paralyse; maag, maagatonie, Gastroparalyse, Gastroparese, Maagverlamming
French Atonie de l'estomac, Paralysie gastrique, Atonie stomacale, ATONIE GASTRIQUE, GASTROPARESIE, Atonie gastrique, Gastroparésie, Stase gastrique
Spanish Atonía de estómago, Estasis gástrica, Parálisis gástrica, GASTRICA, ATONIA, GASTROPARESIA, Gastroparesia, estasis gástrica, síndrome de gastroparesia (trastorno), Gastroparesis, atonía gástrica (trastorno), atonía gástrica, gastroparesia (trastorno), gastroparesia, síndrome de gastroparesia (concepto no activo), síndrome de gastroparesia, Atonía gástrica, estasis gástrico, Estasis Gástrica
Japanese 胃アトニー, 胃内容うっ滞, 胃麻痺, イマヒ, イナイヨウウッタイ, イアトニー, イフゼンマヒ, 胃のうっ滞, 軽症胃アトニー, 胃不全麻痺
Swedish Magmuskelförlamning
Czech žaludek - paréza, gastroparéza, Gastroparéza, Paralýza žaludku, Atonie žaludku, Žaludeční stáza, Žaludeční atonie
Finnish Gastropareesi
Russian GASTROPAREZ, ZHELUDOCHNYI STAZ, ГАСТРОПАРЕЗ, ЖЕЛУДОЧНЫЙ СТАЗ
Polish Gastroplegia, Niedowład żołądka, Zastój żołądkowy, Porażenie żołądka
Hungarian Gyomoratonia, Gyomor paralysis, Gyomor atónia, Gastroparesis, Gyomor atonia, Gyomor atoniája, Gyomor stasis
Norwegian Gastroparese

Ontology: Diabetic gastroparesis (C0267176)

Concepts Disease or Syndrome (T047)
SnomedCT 34140002
Italian Gastroparesi diabetica
Czech Diabetická gastroparéza
Japanese 糖尿病性胃不全麻痺, トウニョウビョウセイイフゼンマヒ
English diabetic gastroparesis, Diabetic gastroparesis, Diabetic gastroparesis (disorder)
Hungarian Diabeteses gastroparesis
Spanish gastroparesia diabética (trastorno), gastroparesia diabética, Gastroparesia diabética
Portuguese Gastroparese diabética
Dutch diabetische gastroparese
French Gastroparésie diabétique
German Diabetische Gastroparese

Ontology: Delayed gastric emptying (C0740411)

Concepts Finding (T033)
SnomedCT 314944001
English Delayed gastric emptying, delayed gastric emptying, delay emptying gastric, delayed empty gastric, Delayed gastric emptying (disorder)
Dutch vertraagde maaglediging
French Vidage gastrique retardé
German verzoegerte Magenentleerung
Italian Svuotamento gastrico ritardato
Portuguese Esvaziamento gástrico retardado
Spanish Vaciamiento gástrico retardado, vaciamiento gástrico tardío (trastorno), vaciamiento gástrico tardío
Japanese 胃排出遅延, イハイシュツチエン
Czech Opožděné vyprazdňování žaludku
Hungarian Késői gyomor ürülés