Gastroparesis

Background

Chronic GI disorder characterized by delayed gastric emptying without mechanical obstruction
More common in women, presumed due to elevated progesterone
Symptoms overlap with functional dyspepsia

Idiopathic (most common)
Diabetes mellitus
Postsurgical/Vagal nerve injury
GI disorders associated with delayed emptying:
- GERD, Achalasia
- Atrophic gastritis, celiac disease
- Functional dyspepsia
- Hypertrophic pyloric stenosis
Non-GI conditions/risk factors associated with delayed gastric emptying
- Medications: opioids, anticholinergics, PPIs, alcohol, tobacco, progesterone
- Eating disorders: Anorexia nervosa
- Parkinson's disease and other neurologic disorders
- Collagen vascular disease
- Parathyroid/thyroid disorder
- Chronic renal insufficiency
- Malignancy
- Ischemic gastroparesis

Definitive diagnosis of gastroparesis not typically made in ED
- Gold standard is gastric emptying scintigraphy of a solid-phase meal
- Other studies assessing emptying: tests, upper GI barium study, ultrasound for changes in antral area
ED workup to exclude alternative diagnoses and complications (e.g. dehydration, Electrolyte abnormalities)
CBC, BMP, LFTs, lipase
Urinalysis, uHCG
Consider:
- ECG (if >50 or at risk for cardiac disease)
- RUQ US
- Acute abdominal series including an upright CXR (if risk for perforated ulcer)
- CT abdomen/pelvis to rule out obstruction
- Upper endoscopy or radiographic upper GI series to exclude mechanical obstruction or ulcer disease

IVF, Electrolyte repletion
Antiemetics
- Dopamine receptor antagonists: Prochlorperazine, promethazine, trimethobenzamide
- Ondansetron
Prokinetic agents: enhance gut contractility
- Metoclopramide
  - Also has antiemetic properties
  - PRN and/or standing dose prior to meals and bedtime
- Erythromycin 125-350mg TID or QID
Refractory disease:
- Nasogastric tube to decompress stomach
- Advanced therapies (not in ED) may include: placement of jejunostomy and/or gastrostomy tube, pyloric injection of botulinum toxin, [[Gastric pacemaker complication|gastric electric stimulation]
Prevention of future exacerbations:
- Review medications, opioids, anticholinergics, PPIs may worsen or trigger symptoms
- Avoid carbonated beverages, alcohol, and tobacco
- Optimize glycemic control in patients with diabetes (hyperglycemia alone can delay gastric emptying)
- Dietary: smaller but more frequent meals, minimize fat/fiber, increase liquid nutrient component

Discharge with outpatient follow up unless:
- Inability to tolerate PO
- Need for ongoing IV rehydration, electrolyte correction, and/or glycemic control

1. Parkman HP, Hasler WL, Fisher RS. American Gastroenterlogical Association technical review on the diagnosis and treatment of gastroparesis. Gastroenterology. 2004; 127(5): 1592-1622.

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