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Key Features

  • Chronic condition characterized by intermittent, waxing and waning symptoms and signs of gastric or intestinal obstruction in the absence of any mechanical lesions

  • Caused by

    • Endocrine disorders (diabetes mellitus, hypothyroidism, cortisol deficiency)

    • Postsurgical (vagotomy, partial gastric resection, fundoplication, gastric bypass, Whipple procedure)

    • Neurologic conditions (Parkinson disease, muscular and myotonic dystrophy, autonomic dysfunction, multiple sclerosis, postpolio syndrome, porphyria)

    • Rheumatologic conditions (progressive systemic sclerosis)

    • Infections (postviral, Chagas disease)

    • Amyloidosis

    • Paraneoplastic syndromes

    • Medications

    • Anorexia nervosa

  • Cause may not always be identified

Clinical Findings

  • Manifestations of gastroparesis may be chronic or intermittent

  • Early satiety, bloating, nausea, and vomiting (1–3 hours after meals)

  • Pylorospasm

  • Antral hypomotility

Diagnosis

  • Abdominal radiography shows dilatation of the stomach, esophagus, small intestine, or colon resembling ileus or mechanical obstruction

  • Endoscopy or CT or barium enterography excludes mechanical obstruction

  • Gastric scintigraphy with a low-fat solid meal assesses gastric emptying

  • Gastric retention of 60% of the meal after 2 hours or more than 10% after 4 hours is abnormal

  • Both a wireless motility capsule and a non-radioactive, 13-C labeled blue-green algae (Spirulina platensis) have been FDA approved to assess gastric emptying time

  • Small bowel manometry is useful

    • For distinguishing visceral from myopathic disorders

    • For excluding cases of mechanical obstruction that are otherwise difficult to diagnose by endoscopy or radiographic studies

Treatment

  • No specific therapy

  • Acute exacerbations

    • Nasogastric suction and intravenous fluids

    • Correction of electrolyte disturbance

  • Long-term treatment

    • Small, frequent meals low in fiber, milk, gas-forming foods, and fat

    • Well-tolerated foods include tea, ginger ale, soup, white rice, potatoes and sweet potatoes, fish, gluten-free foods, and applesauce

  • Jejunal feeding via external feeding tube or jejunostomy if oral feeding cannot meet nutritional needs

  • Parenteral nutrition seldom required unless there is a diffuse gastric and intestinal motility disorder

  • Avoid opioids and anticholinergics

  • In persons with diabetes, maintain glucose levels < 200 mg/dL

  • Metoclopramide

    • 5–20 mg four times daily orally

    • 5–10 mg intravenously or subcutaneously before meals

    • Avoid using for more than 3 months because of an increased risk of tardive dyskinesia

  • Domperidone

    • 20–30 mg four times daily

    • Enhances gastric emptying and has efficacy as an antiemetic agent

    • Does not cause neuropsychiatric side effects because it does not cross the blood-brain barrier

    • Unavailable in the United States, but it is preferred therapy in most other countries where it is available

  • Erythromycin, 50–125 mg three times daily orally

  • Venting gastrostomy may be needed in patients with predominant small bowel distention to relieve distress

  • Gastric electrical stimulation with internally implanted neurostimulators reduces nausea and vomiting in patients with severe gastroparesis (especially diabetic patients)

  • Uncontrolled studies report symptom improvement with modalities that reduce intrapyloric pressure, including botulinum toxin injection, laparoscopic myotomy, and endoscopic myotomy

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