Gastroparesis & Chronic Intestinal Pseudo-obstruction

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), epigastric pain

• Abdominal distention, vomiting, diarrhea, and malnutrition may be seen in those with small bowel involvement

• Colonic involvement may cause constipation or alternating diarrhea and constipations

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, fat, milk, and gas-forming foods

  • 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

  • Discontinue after 3 months if neuromuscular side effects, particularly involuntary movements, develop

• 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

• Prucalopride, 2 mg daily orally

• Tradipitant, 85 mg twice daily orally (not yet FDA approved)

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

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