Gastroparesis

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Gastroparesis
Classification & external resources
ICD-10 K31.8
ICD-9 536.3
DiseasesDB 32575
MeSH D018589

Gastroparesis, also called delayed gastric emptying, is a disorder in which the stomach takes too long to empty its contents.

Gastroparesis happens when nerves to the stomach are damaged or stop working. The vagus nerve controls the movement of food through the digestive tract. If the vagus nerve is damaged, the muscles of the stomach and intestines do not work normally, and the movement of food is slowed or stopped.

Contents

[edit] Major causes of gastroparesis

Gastroparesis often occurs in people with type 1 diabetes or type 2 diabetes. Diabetes can damage the vagus nerve if blood glucose levels remain high over a long period of time. High blood glucose causes chemical changes in nerves and damages the blood vessels that carry oxygen and nutrients to the nerves.

[edit] Signs and symptoms

  • heartburn
  • nausea
  • vomiting of undigested food
  • an early feeling of fullness when eating
  • weight loss
  • abdominal bloating
  • erratic blood glucose levels
  • lack of appetite
  • gastroesophageal reflux
  • spasms of the stomach wall

These symptoms may be mild or severe, depending on the person.

[edit] Complications of gastroparesis

If food lingers too long in the stomach, it can cause problems like bacterial overgrowth from the fermentation of food. Also, the food can harden into solid masses called bezoars that may cause nausea, vomiting, and obstruction in the stomach. Bezoars can be dangerous if they block the passage of food into the small intestine.

Gastroparesis can make diabetes worse by adding to the difficulty of controlling blood glucose. When food that has been delayed in the stomach finally enters the small intestine and is absorbed, blood glucose levels rise. Since gastroparesis makes stomach emptying unpredictable, a person's blood glucose levels can be erratic and difficult to control.

[edit] Diagnosis

The diagnosis of gastroparesis is confirmed through one or more of the following tests.

Some centers still use a barium beefsteak meal to look for problems of stomach emptying. Yet, this test is not at all reliable for detecting delayed gastric emptying. The barium contrast material is a liquid and is much heavier than normal food. Therefore, gravity allows the separation and movement of barium out of the stomach and does not give meaningful information regarding the stomach's emptying power.

A GET, or gastric emptying test, is commonly used to diagnose gastroparesis. Using a method called scintigraphy a gamma emitting radioisotope is integrated into a selected food item, often scrambled eggs. Multi-centre clinical trials have established international standards for this test. The meal is eaten and images, utilizing a gamma camera, are taken of the stomach over a period of up to 4 hours.

While the American Motility Society is working to standardize the GET tests, presently the duration at which Gastric Emptying Studies are carried out, as well as the test meals used, can vary significantly from institution to institution. Research has shown that the diagnosis of Gastroparesis can be missed in some individuals if the GET is carried out for only two hours - and some centers still use a two-hour study.

A multi-center study has established normal ranges for gastric emptying in healthy subjects at time intervals of 60, 120, and 240 minutes after completion of a consistent radio-tagged low-fat meal. Average gastric retention in healthy subjects; at 1 hour, 2 hours, and 4 hours was 90%, 60% and 10% respectively. These values are for adults only. Standards have not been established for children.

The 4-hour Gastric Emptying Time is now becoming the standard test, using a low-fat egg substitute meal to minimize the effect of fat on gastric emptying.


  • Barium x-ray . May be perfored to look for any structral abnormalities within the stomach and upper gastrointestinal tract. After fasting for 12 hours, you will drink a thick liquid called barium, which coats the inside of the stomach, making it show up on the x ray. Normally, the stomach will be empty of all food after 12 hours of fasting. If the x ray shows food in the stomach, gastroparesis is likely. If the x ray shows an empty stomach but the doctor still suspects that you have delayed emptying, you may need to repeat the test another day. On any one day, a person with gastroparesis may digest a meal normally, giving a falsely normal test result. If you have diabetes, your doctor may have special instructions about fasting.


Antral duodenal manometry (also know as motility testing) is a means by which the pressure from peristaltic action inside the digestive tract can be measured. A thin tube is passed down the throat. While manometry is commonly performed on the esophagus, very few centers provide this test on the stomach and small bowel. When this test is performed on the stomach, it helps to reveal the pumping power and capabilities of the lower part of the stomach, or antrum. In gastroparesis, the function of the antrum is frequently found to be weak and inadequate. As well, during studies on the stomach, manometric measures performed on the pylorus may be helpful in demonstrating pyloro-spasm - another common problem found with delayed gastric emptying.


  • Blood tests. The doctor may also order laboratory tests to check blood counts and to measure chemical and electrolyte levels.

To rule out causes of gastroparesis other than diabetes, the doctor may do an upper endoscopy or an ultrasound.

  • Upper endoscopy. After giving you a sedative, the doctor passes a long, thin tube called an endoscope through the mouth and gently guides it down the esophagus into the stomach. Through the endoscope, the doctor can look at the lining of the stomach to check for any abnormalities.
  • Ultrasound. To rule out gallbladder disease or pancreatitis as a source of the problem, you may have an ultrasound test, which uses harmless sound waves to outline and define the shape of the gallbladder and pancreas.

[edit] Treatment

The primary treatment goal for gastroparesis related to diabetes is to regain control of blood glucose levels. Treatments include insulin, oral medications, changes in what and when you eat, and, in severe cases, feeding tubes and intravenous feeding.

It is important to note that in most cases treatment does not cure gastroparesis--it is usually a chronic condition. Treatment helps you manage the condition so that you can be as healthy and comfortable as possible.

[edit] Insulin for blood glucose control

Gastroparesis leads to slower and irregular food absorption. As a result blood sugar levels need to be monitored more frequently and insulin administration adjusted accordingly.

[edit] Medication

Several drugs are used to treat gastroparesis. Your doctor may try different drugs or combinations of drugs to find the most effective treatment.

  • Metoclopramide (Reglan). This drug stimulates stomach muscle contractions to help empty food. It also helps reduce nausea and vomiting. Metoclopramide is taken 20 to 30 minutes before meals and at bedtime. Side effects of this drug are fatigue, sleepiness, and sometimes depression, anxiety, and problems with physical movement. The Food and Drug Administration advises: "Tardive Dyskinesia, a syndrome consisting of potentially irreversible, dyskinetic movements may develop in patients treated with metoclopramide...Both the risk of developing the syndrome and the likelihood that it will become irreversible are believed to increase with the duration of treatment and the total cumulative dose." As with any medication, you should discuss all potential benefits, potential risks, and potential side effects with your physician.
  • Erythromycin. This antibiotic also improves stomach emptying. It works by increasing the contractions that move food through the stomach. Side effects are nausea, vomiting, and abdominal cramps.
  • Domperidone. This drug helps initiate contractions of the stomach, as well as alleviate nausea. Unlike Metoclopramide, it is too large to cross the blood brain barrier, and does not cause neurological symptoms. It is currently not approved in the United States by the FDA.
  • Cisapride is a 5-HT4 receptor agonist which was formerly the drug of choice for dealing with gastroparesis. Its use has sharply declined after finding that it causes cardiac dysrhythmias. It is still available for special cases.
  • Tegaserod. This 5-HT4 receptor agonist encourages stomach motility, without the heart side effects of Cisapride.
  • Other medications. Other medications may be used to treat symptoms and problems related to gastroparesis. For example, an antiemetic can help with nausea and vomiting. There are several other classes of medication that are less often used to treat gastroparesis. Muscarinic receptor agonists, acetylcholinesterase inhibitors, and CCK receptor antagonists have been shown to have prokinetic functions. Antibiotics will clear up a bacterial infection. If you have a bezoar, the doctor may use an endoscope to inject medication that will dissolve it.

[edit] Meal and food changes

Changing your eating habits can help control gastroparesis. Your doctor or dietitian will give you specific instructions, but you may be asked to eat six small meals a day instead of three large ones. If less food enters the stomach each time you eat, it may not become overly full. Or the doctor or dietitian may suggest that you try several liquid meals a day until your blood glucose levels are stable and the gastroparesis is corrected. Liquid meals provide all the nutrients found in solid foods, but can pass through the stomach more easily and quickly.

The doctor may also recommend that you avoid high-fat and high-fiber foods. Fat naturally slows digestion--a problem you do not need if you have gastroparesis--and fiber is difficult to digest. Some high-fiber foods like oranges and broccoli contain material that cannot be digested. Avoid these foods because the indigestible part will remain in the stomach too long and possibly form bezoars.

Acid buildup leading to acid reflux can normally be handled with histamine receptor antagonists like Zantac or Nexium. Also helpful is a daily dosage of curcumin, an ingredient found in the spice tumeric. However, none of these initiate the contractions necessary to help empty the stomach. That process will require additional medication such as Domperidone.

[edit] Feeding tube

If other approaches do not work, you may need surgery to insert a feeding tube. The tube, called a jejunostomy tube, is inserted through the skin on your abdomen into the small intestine. The feeding tube allows you to put nutrients directly into the small intestine, bypassing the stomach altogether. You will receive special liquid food to use with the tube. A jejunostomy is particularly useful when gastroparesis prevents the nutrients and medication necessary to regulate blood glucose levels from reaching the bloodstream. By avoiding the source of the problem--the stomach--and putting nutrients and medication directly into the small intestine, you ensure that these products are digested and delivered to your bloodstream quickly. A jejunostomy tube can be temporary and is used only if necessary when gastroparesis is severe.

[edit] Parenteral nutrition

Parenteral nutrition refers to delivering nutrients directly into the bloodstream, bypassing the digestive system. The doctor places a thin tube called a catheter in a chest vein, leaving an opening to it outside the skin. For feeding, you attach a bag containing liquid nutrients or medication to the catheter. The fluid enters your bloodstream through the vein. Your doctor will tell you what type of liquid nutrition to use.

This approach is an alternative to the jejunostomy tube and is usually a temporary method to get you through a difficult spell of gastroparesis. Parenteral nutrition is used only when gastroparesis is severe and is not helped by other methods.

[edit] New treatments

A gastric neurostimulator has been developed to assist people with gastroparesis. The battery-operated device is surgically implanted and emits mild electrical pulses which help to control the symptoms of nausea and vomiting associated with gastroparesis. This option is available to people whose nausea and vomiting do not improve with medications.

The use of botulinum toxin has been shown to improve stomach emptying and the symptoms of gastroparesis by decreasing the prolonged contractions of the muscle between the stomach and the small intestine (pyloric sphincter). The toxin is injected into the pyloric sphincter.

[edit] See also

[edit] References

[edit] External links

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Health science - Medicine - Gastroenterology (primarily K)
esophagus - stomach: Halitosis | Nausea | Vomiting | Heartburn | GERD | Achalasia | Esophageal cancer | Esophageal varices | Peptic ulcer | Abdominal pain | Stomach cancer | Non-ulcer dyspepsia | Gastroparesis
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small intestine: Peptic ulcer | Intussusception | Malabsorption (e.g. coeliac, lactose intolerance, fructose malabsorption, Whipple's) 
colon: Diarrhea | Appendicitis | Diverticulitis | Diverticulosis | IBD (Crohn's, Ulcerative colitis) 
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