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Complications and Comorbidities> Gastrointestinal>
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Gastroparesis

Octavia Pickett-Blakely, M.D. and Mimi Huizinga, M.D.
04-30-2010

DEFINITION

  • Delayed gastric emptying in the absence of a mechanical gastric outlet obstruction
  • The result of hyperglycemia-associated autonomic dysfunction and vagus nerve damage 
  • Absence of other etiologies of delayed gastric emptying (e.g. narcotics, previous vagotomy)

EPIDEMIOLOGY

  • Diabetes is the most common known cause of gastroparesis. 
  • Up to 50% of patients with diabetes have objective evidence of delayed gastric emptying but may not have clinical manifestations. (Kong)
  • Female sex and the presence of autonomic neuropathy, retinopathy, and renal microvasculopathy are positive predictors of delayed gastric emptying in diabetes. (Jones, Kockar)

DIAGNOSIS

  • Clinical history suggestive of gastroparesis (see Signs and Symptoms, below).
  • Objective evidence of abnormal solid phase gastric emptying by scintigraphy, retained gastric contents noted on upper endoscopy or barium X-ray.
  • Scintigraphy measures the rate of exit (in minutes) of a radioisotope labeled solid and liquid meal ingested by the patient. Delayed gastric emptying is greater than 10% of the meal retained in the stomach 4 hours after ingestion. (Camilleri)
  • Liquid phase gastric emptying is often normal and thus, is not useful in the diagnosis of diabetic gastroparesis.(Tack)
  • Other methods to objectively measure gastric emptying: isotope labeled breath test (not available in the U.S.), wireless capsule endoscopy (not commonly used), antroduodenal manometry.

SIGNS AND SYMPTOMS

  • Early satiety
  • Abdominal pain
  • Nausea
  • Vomiting
  • Bloating
  • Postprandial fullness
  • Physical examination findings suggestive of volume depletion, epigastric distension, epigastric tenderness
  • Presence of autonomic neuropathy and/or other diabetes complications

CLINICAL TREATMENT

Dietary therapy

  • Small frequent meals with low fiber and fat content
  • Nutritional supplementation if dietary intake needs are not met (via oral supplements, post-pyloric enteral nutrition or parental nutrition)
Medical therapy

  • Prokinetic therapy: first line therapy which includes metoclopramide, erythromycin, domperidone (available in Canada and Europe)
  • Metoclopramide is most commonly used in the U.S. but its use is limited by neurologic side effects like tardive dyskinesia, while erythromycin use can be complicated by prolongation of the QT interval and tachyphalaxis.(Haans)
  • Symptomatic therapy: antiemetics and non-narcotic analgesics (usually used in addition to prokinetics as second line agents)
Endoscopic/Surgical therapy

  • Pyloric botulinum toxin injection has been utilized, however, large randomized trials are needed to evaluate this treatment. Its current use is in those refractory to medical therapy and the duration of effect (if effective) is variable. (Haans, DeSantis)
  • Gastric electrical stimulators have been shown to improve symptoms in patients refractory to medical therapy without necessarily any improvement in gastric emptying compared to placebo. (Haans, Tack)
  • Roux-en-Y gastric bypass reduces the symptoms of gastroparesis in patients with diabetes who are having a bariatric surgery procedure for weight loss.

FOLLOW UP

  • Patients should be followed in short, frequent intervals as an outpatient.
  • Screening for micronutrient deficiencies should be performed in patients with significant weight loss and/or malnutrition.
  • Patients should be followed by a nutritionist/dietitian.
  • Referral to a gastroenterologist is recommended in patients with symptoms suggestive of gastroparesis. Additional work-up including upper endoscopy may be warranted to investigate other etiologies of symptoms.

EXPERT COMMENTS

  • Diabetic gastroparesis is a difficult entity to diagnose and treat.
  • The medical management of diabetic gastroparesis is limited by few options with debilitating side effects.
  • There is poor symptom correlation with objective studies of gastric emptying which further complicates the disease management.
  • Diabetic gastroparesis can result in erratic glycemic control as a result of unpredictable oral intake and nutrient absorption.
  • Although suboptimal glycemic control has been positively associated with delayed gastric emptying and gastroparesis- related hospitalizations, there is little prospective data to suggest that euglycemia improves diabetic gastroparesis outcomes. (Uppalapati)

REFERENCES

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