The patient presented with abdominal pain, bloating, nausea and early satiety. A variety of symptoms suggest the possibility of gastroparesis. For patients suspected of having gastroparesis, an identifiable cause should be sought. The differential diagnosis should include diabetes mellitus, as it is prevalent in these patients. In the community setting, 5% of patients with type 1 diabetes, 1% of patients with type 2 diabetes, and approximately 0.2% of non-diabetic patients develop gastroparesis.
The American Gastrointestinal Association Writing Committee recommends taking a detailed patient history, as gastroparesis often begins after a viral illness. Patients will often say, “I was fine until I got this disease and started getting nausea and vomiting.” Look for prodromal symptoms of viral disease and evaluate the patient’s history of diabetes, gastric surgery, fundoplication, thyroid disease, endocrine and rheumatic diseases. If the patient has any of these conditions, they should be tested appropriately.
Gastroparesis is a very common condition. It is prevalent in postoperative patients, especially after fundoplication
Gastroparesis is defined as a patient with evidence of delayed gastric emptying, but no evidence of gastric outlet obstruction. Clinical features may overlap with conditions such as functional dyspepsia or accelerated gastric emptying. Symptoms and presentations must correlate with objective evidence based on diagnostic tests.
Diagnosis of gastroparesis
A 4-hour gastric emptying deficit of 50% is consistent with a diagnosis of gastroparesis.
Novel diagnostic tests include the 13C respiratory test and the wireless power capsule test, but data on these tests need to be validated before they can replace the diagnostic gold standard.
Ruling out other diagnoses is also a concern. Physicians are advised to consider other diagnoses. In addition to diabetes and rheumatic, endocrine, neurologic, and postoperative disorders, other differential diagnoses that should be considered include feeding disorders such as anorexia and bulimia. Patients with these disorders may have delayed gastric emptying on testing. Another differential diagnosis is periodic vomiting syndrome. Some symptoms may overlap with those of gastroparesis and require further evaluation.
Treatment of Gastroparesis
What are the current treatment recommendations?
First, look for and correct any electrolyte disturbances that may be caused by gastroparesis. Depending on the electrolyte profile of the patient, enteral nutrition may have to be supplemented.
These patients should be evaluated by a dietitian or dietician to review their dietary intake and investigate micronutrient and macronutrient deficiencies.
Have these patients eat small, frequent meals and consume simple, soft cooked foods that are low in fat and dregs.
Drug selection
It is important to demonstrate gastroparesis before starting treatment options.
Prokinetic agents, especially metoclopramide, are the mainstay of treatment. Over time, this drug can also lead to rapid tolerance. Clinicians should monitor patients for neurological side effects if using this drug.
Domperidone is another option and does not cause neurological side effects. Domperidone has the potential to cause hyperprolactinemia, so women may sometimes have nipple discharge. Recently, questions have been raised about the availability of domperidone. The FDA is currently researching alternative ways to obtain domperidone.
If the drug is used, it is important to perform a baseline ECG because domperidone is a class of drug that can cause QT prolongation. Domperidone should not be used if the patient’s QT interval exceeds 470 msec (men) or 450 msec (women). It is also recommended that after a patient starts domperidone, a follow-up ECG should be obtained to ensure that QT prolongation has not occurred.
Erythromycin is another drug used to treat gastroparesis. Data on erythromycin show short-term effectiveness, but rapid tolerance usually occurs. Erythromycin is a gastrokinetic agonist that works by increasing the migrating motor complex wave and gastric emptying, but I have found that many patients experience severe colic with this drug.
Elixirs are preferable to tablets because the stomach empties fluid more easily than tablets. Erythromycin can also prolong the QT interval, so patients must be monitored for this side effect. Erythromycin is metabolized through the CYP3A4 pathway, so it is important to know what other drugs the patient is using that are also metabolized through this pathway.
Botulinum toxin type A injections are commonly used to treat gastroparesis, especially when the disease is corrected by endoscopy.
Surgical and other options
In severely debilitated patients, it is suggested that in rare cases, a gastrectomy may be useful. Vagotomy and gastric resection that is more dependent on food dumping into the jejunum may be considered, but these are patients who are already at increased surgical risk. Construction of a gastric outlet through a gastrostomy or placement of a jejunal feeding tube by percutaneous endoscopic gastrostomy are other options for refractory patients. Risks should be assessed prior to performing either of these operations.