GASTROPARESIS

“Gastroparesis is a symptomatic chronic disorder of the stomach characterized by delayed gastric emptying in the absence of mechanical obstruction.”

Table 1. Evaluation of Patients Suspected to Have Gastroparesis

1. Initial investigation
A. History and physical examination
B. Blood tests
-Complete blood count
-Complete metabolic profile, including glucose, potassium, creatinine, total protein, albumin, calcium
-Amylase, if abdominal pain is significant symptom
-Pregnancy test, if appropriate
C. Abdominal obstruction series, if vomiting or pain is acute or severe
2. Evaluate for organic disorders
A. Upper endoscopy to evaluate for mechanical obstruction or mucosal lesions (alternative: barium upper gastrointestinal series, often with small bowel
follow-through)
B. Biliary ultrasonography if abdominal pain is a significant symptom
3. Evaluate for delayed gastric emptying
A. Solid-phase gastric emptying test
B. Screen for secondary causes of gastroparesis
-Thyroid function tests (thyroid-stimulating hormone)
-Rheumatologic serologies (eg, antinuclear antibody, scleroderma antibody [Scl70])
-Glycosylated hemoglobin (HbA1C)
4. Treatment trial with prokinetic agent and/or antiemetic agent
5. If no clinical response, consider further investigation
A. EGG
B. Antroduodenal manometry
C. Small bowel evaluation with enteroclysis or small bowel followthrough
D. Further laboratory tests, if indicated ANNA, tissue transglutaminase antibody
*table adopted from reference 1

Table 4. Etiology of Gastroparesis (Nonobstructive Delayed Gastric Emptying)

*Idiopathic
*Diabetes mellitus
*Postsurgical:
Partial gastric resection/vagotomy, Postbariatric surgery, Nissen fundoplication, Transplantation: lung, heart-lung
Gastrointestinal disorders associated with delayed gastric emptying
Diffuse gastrointestinal motor disorders (eg, chronic intestinal pseudo-obstruction)
GERD
Achalasia
Gastric ulcer
Atrophic gastritis
Functional dyspepsia
Hypertrophic pyloric stenosis
Celiac disease
Nongastrointestinal disorders associated with delayed gastric emptying
Eating disorders: anorexia
Neurologic disorders
CNS tumors, Parkinson’s disease
Collagen vascular disorders
Scleroderma, Systemic lupus erythematosus
Amyloidosis
Endocrine and metabolic disorders
Thyroid dysfunction, Parathyroid dysfunction, Chronic renal insufficiency
Gastric infection
Chronic mesenteric ischemia
Tumor associated (paraneoplastic)
Medication associated
*table adopted from reference 1

Treatment:
- treat underlying cause & symptomatic management (medication review, BG control), dietary manipulation, Rx: antiemetic/prokinetic agents
- diet: frequent small meals, low fat/fiber, increase liquid intake (severe cases: jejunal feeding vs. TPN)
- antiemetics: anti-DA, AH, anti-Ach*, anti-5HT3 (*delays gastric emptying)
- prokinetics: metoclopramide, erythromycin [cisapride, domperidone – not available in USA]
Refractory Gastroparesis:
- combination of prokinetics, pyloric botulism toxin injection, TCAs (nortriptyline, desipramine), gastric electric stimulation, venting gastrostomy +/-
feeding jejunostomy

References:
1. Parkman, Henry P., William L. Hasler and Robert S. Fisher. "American Gastroenterological Association technical review on the diagnosis and treatment of
gastroparesis." Gastroenterology 127.5 (2004):1592-1622.
2. Parkman, Henry P., William L. Hasler and Robert S. Fisher. "American Gastroenterological Association medical position statement: diagnosis and treatment of
gastroparesis." Gastroenterology 127.5 (2004):1589-1591.