Gastroparesis

A chronic digestive disorder affecting stomach muscle movement and gastric emptying

Contents

Common Symptoms

Overview

Gastroparesis is a chronic digestive disorder characterized by delayed gastric emptying without mechanical obstruction. The condition occurs when the stomach muscles don't work properly, preventing normal movement of food from the stomach to the small intestine. This gastroparesis affects an estimated 5 million people in the United States, with women being affected more frequently than men.

The term "gastroparesis" literally means "stomach paralysis," although the stomach isn't completely paralyzed in most cases. Instead, the normal rhythmic contractions of the stomach are significantly impaired, leading to food remaining in the stomach for prolonged periods. This delayed gastric emptying can cause various uncomfortable symptoms and potentially serious complications.

There are several types of gastroparesis, including diabetic gastroparesis (the most common form), idiopathic gastroparesis (of unknown cause), and gastroparesis secondary to medications, surgery, or other medical conditions. The severity can range from mild symptoms that are manageable with dietary changes to severe cases requiring invasive treatments and frequent hospitalizations.

Early recognition and appropriate management are crucial for preventing complications such as malnutrition, dehydration, and dangerous blood sugar fluctuations in diabetic patients. While gastroparesis is a chronic condition that cannot be cured, various treatments can help manage symptoms and improve quality of life.

Symptoms

Gastroparesis symptoms can vary significantly in severity and may fluctuate over time. Some patients experience mild, intermittent symptoms, while others have severe, persistent problems that significantly impact their daily life.

Primary Digestive Symptoms

  • Nausea: Often the most prominent symptom, ranging from mild queasiness to severe, persistent nausea
  • Vomiting: May occur after meals and can contain undigested food eaten hours or days earlier
  • Sharp abdominal pain: Often located in the upper abdomen and may be cramping in nature
  • Burning abdominal pain: Persistent burning sensation in the stomach area
  • Upper abdominal pain: Discomfort in the epigastric region, often worsening after meals

Secondary Symptoms

  • Regurgitation: Undigested food returning to the mouth without nausea or retching
  • Early satiety: Feeling full quickly after eating small amounts of food
  • Bloating and distension: Feeling of fullness and visible abdominal swelling
  • Loss of appetite: Decreased desire to eat due to persistent symptoms
  • Weight loss: Often unintentional due to poor food intake and malabsorption

Systemic Symptoms

  • Fatigue: Due to poor nutrition and chronic illness
  • Malnutrition: Deficiencies in vitamins and minerals from poor absorption
  • Dehydration: From vomiting and reduced fluid intake
  • Blood sugar fluctuations: Particularly problematic in diabetic patients

Symptom Patterns

Symptoms often worsen after eating, particularly after consuming high-fiber, high-fat, or large meals. Some patients experience symptom flares that can last days to weeks, followed by periods of relative improvement. Stress, illness, and poor blood sugar control can trigger symptom exacerbations.

Causes

Gastroparesis can result from various underlying conditions and factors that damage the vagus nerve or affect the stomach's muscle function. Understanding the cause is important for determining the most appropriate treatment approach.

Diabetic Gastroparesis

Diabetes mellitus is the most common identifiable cause of gastroparesis, accounting for approximately 30% of cases. High blood glucose levels over time can damage the vagus nerve, which controls stomach muscle contractions. Both type 1 and type 2 diabetes can lead to gastroparesis, with the risk increasing with duration of diabetes and poor glycemic control.

Idiopathic Gastroparesis

Approximately 35-50% of gastroparesis cases are idiopathic, meaning no specific cause can be identified. These cases may result from unrecognized viral infections, genetic factors, or autoimmune processes that affect gastric motility.

Post-Surgical Gastroparesis

Certain surgical procedures can damage the vagus nerve or affect stomach function:

  • Vagotomy (surgical cutting of the vagus nerve)
  • Gastric bypass surgery
  • Partial gastrectomy
  • Fundoplication surgery
  • Other abdominal surgeries affecting gastric innervation

Medication-Induced Gastroparesis

Various medications can slow gastric emptying:

  • Opioid pain medications: Morphine, oxycodone, fentanyl
  • Anticholinergic drugs: Medications that block acetylcholine
  • Tricyclic antidepressants: Amitriptyline, nortriptyline
  • Calcium channel blockers: Some blood pressure medications
  • GLP-1 receptor agonists: Certain diabetes medications

Other Medical Conditions

Risk Factors

Several factors increase the likelihood of developing gastroparesis:

Medical Risk Factors

  • Diabetes mellitus: Especially with poor blood sugar control or long duration
  • Previous gastric surgery: Any surgery involving the stomach or vagus nerve
  • Autoimmune diseases: Conditions affecting connective tissue or nerve function
  • Neurological disorders: Diseases affecting the central or peripheral nervous system
  • Eating disorders: Particularly anorexia nervosa with severe weight loss

Demographic Factors

  • Gender: Women are affected more frequently than men
  • Age: Can occur at any age but often diagnosed in middle age
  • Family history: May have genetic predisposition in some cases

Lifestyle and Environmental Factors

  • Chronic medication use: Long-term use of medications that affect gastric motility
  • Viral infections: Previous gastroenteritis or other viral illnesses
  • Stress: Chronic stress may worsen existing gastroparesis
  • Smoking: May impair gastric function and healing

Diagnosis

Diagnosing gastroparesis requires a combination of clinical evaluation, symptom assessment, and specialized tests to measure gastric emptying. The diagnostic process aims to confirm delayed gastric emptying and identify any underlying causes.

Clinical Evaluation

The healthcare provider will conduct a thorough history and physical examination, focusing on:

  • Symptom duration, severity, and patterns
  • Medical history, including diabetes and previous surgeries
  • Current medications that may affect gastric motility
  • Dietary habits and weight changes
  • Family history of gastrointestinal disorders

Gastric Emptying Studies

  • Gastric emptying scintigraphy: The gold standard test involving consumption of a radioactive meal followed by imaging to track stomach emptying over 4 hours
  • Wireless motility capsule: A pill-sized device that measures pH, pressure, and temperature as it moves through the digestive tract
  • Gastric emptying breath test: Measures carbon dioxide in breath after consuming a meal containing a carbon isotope
  • Upper endoscopy: May show retained food in the stomach despite fasting

Additional Tests

  • Upper GI series: Barium X-rays to evaluate stomach structure and function
  • CT or MRI scan: To rule out mechanical obstruction
  • Electrogastrography: Measures electrical activity of stomach muscles
  • Blood tests: To check for diabetes, thyroid function, and other conditions

Differential Diagnosis

Healthcare providers must distinguish gastroparesis from other conditions with similar symptoms:

Treatment Options

Treatment for gastroparesis is individualized based on symptom severity, underlying cause, and patient factors. The approach typically involves dietary modifications, medications, and in severe cases, surgical interventions.

Dietary Management

Dietary modifications are often the first-line treatment and can significantly improve symptoms:

  • Small, frequent meals: Eating 4-6 small meals instead of 3 large ones
  • Low-fiber diet: Reducing insoluble fiber that can form bezoars
  • Low-fat foods: Fats slow gastric emptying
  • Liquid and pureed foods: Easier to empty from the stomach
  • Avoid carbonated beverages: Can increase bloating and discomfort
  • Limit alcohol: Can worsen gastroparesis symptoms

Medications

  • Prokinetic agents:
    • Metoclopramide: Stimulates gastric contractions but has significant side effects
    • Domperidone: Similar to metoclopramide with fewer central nervous system effects
    • Erythromycin: Antibiotic with prokinetic properties for short-term use
  • Antiemetic medications:
    • Ondansetron (Zofran): 5-HT3 receptor antagonist
    • Promethazine: Phenothiazine antiemetic
    • Prochlorperazine: For severe nausea and vomiting
  • Gastric acid suppression:
    • Proton pump inhibitors: Reduce acid production
    • H2 receptor blockers: Alternative acid suppression

Advanced Therapies

  • Gastric electrical stimulation: Implanted device that stimulates stomach muscles
  • Botulinum toxin injection: Injected into the pyloric sphincter to improve emptying
  • Peroral endoscopic pyloromyotomy (POEM): Endoscopic procedure to open the pyloric sphincter
  • Surgical pyloroplasty: Surgical widening of the pyloric opening

Nutritional Support

  • Nutritional supplements: Vitamins and minerals to prevent deficiencies
  • Jejunostomy feeding: Direct feeding into the small intestine for severe cases
  • Total parenteral nutrition: Intravenous nutrition for patients unable to tolerate enteral feeding

Blood Sugar Management

For diabetic patients, optimizing blood sugar control is crucial and may require:

  • Frequent blood glucose monitoring
  • Insulin regimen adjustments
  • Continuous glucose monitoring
  • Working closely with endocrinologist

Prevention

While not all cases of gastroparesis can be prevented, certain measures may reduce the risk or prevent worsening of the condition:

Diabetic Prevention

  • Optimal blood sugar control: Maintaining HbA1c levels as close to normal as possible
  • Regular monitoring: Frequent blood glucose checks and medical follow-up
  • Diabetic education: Understanding proper diabetes management
  • Early intervention: Prompt treatment of diabetic complications

Medication Management

  • Avoid problematic medications: When possible, limit use of drugs that slow gastric emptying
  • Regular medication review: Discuss alternatives with healthcare providers
  • Opioid alternatives: Consider non-opioid pain management strategies

Lifestyle Modifications

  • Healthy diet: Maintain good nutrition and avoid trigger foods
  • Regular exercise: Physical activity may help gastric motility
  • Stress management: Stress reduction techniques and adequate sleep
  • Avoid smoking and excessive alcohol: Both can impair gastric function

When to See a Doctor

Seek medical evaluation if you experience persistent digestive symptoms that interfere with daily life or nutrition. Early diagnosis and treatment can prevent complications and improve quality of life.

Emergency Situations

  • Severe dehydration or inability to keep fluids down
  • Signs of severe malnutrition or significant weight loss
  • Persistent vomiting lasting more than 24 hours
  • Diabetic patients with erratic blood sugar control
  • Signs of gastric obstruction or perforation
  • Severe abdominal pain with fever

Routine Medical Consultation

  • Persistent nausea and vomiting after meals
  • Chronic upper abdominal pain or burning
  • Early satiety and unintentional weight loss
  • Frequent regurgitation of undigested food
  • Worsening of diabetes control
  • Symptoms interfering with nutrition or daily activities

Specialist Referral

Consider referral to a gastroenterologist for specialized evaluation and treatment if symptoms persist despite initial management. Endocrinologist consultation may be needed for diabetic patients with poorly controlled blood sugar.

Related Conditions

Several conditions are associated with or commonly confused with gastroparesis:

Associated Digestive Disorders

Underlying Medical Conditions

Complications

  • Malnutrition: From poor food intake and absorption
  • Dehydration: From persistent vomiting
  • Gastric bezoars: Food masses that can cause obstruction
  • Aspiration pneumonia: From regurgitation and aspiration

References

  1. Camilleri, M., Chedid, V., Ford, A. C., et al. (2018). Gastroparesis. Nature Reviews Disease Primers, 4(1), 41.
  2. Bharucha, A. E., Kudva, Y. C., & Prichard, D. O. (2019). Diabetic gastroparesis. Endocrine Reviews, 40(5), 1318-1352.
  3. Parkman, H. P., Yates, K., Hasler, W. L., et al. (2011). Clinical features of idiopathic gastroparesis vary with sex, symptom onset, delay in diagnosis, and gastroparesis severity. Gastroenterology, 140(1), 101-115.
  4. Abell, T. L., Camilleri, M., Donohoe, K., et al. (2008). Consensus recommendations for gastric emptying scintigraphy: a joint report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine. Gastroenterology, 135(4), 1445-1456.