Gastroparesis: Approach, Diagnostic Evaluation, and Management
Introduction
Gastroparesis, or delayed gastric emptying, is a motility disorder of the stomach that is characterized by slowed emptying of food in the absence of mechanical obstruction.1, 2 Normal gastric motor function is a coordinated sequence of events influenced by the autonomic nervous system, smooth muscle cells, and enteric neurons.3 Disturbances of any of these control pathways can lead to delayed gastric emptying or gastric stasis. A range of causes has been identified, most notably idiopathic, diabetic, and postsurgical etiologies.1, 4 Symptoms of gastroparesis are variable and nonspecific, but the most common include nausea, vomiting, bloating, early satiety, and abdominal pain.4 As the severity of gastroparesis progresses, other disorders or complications, such as esophagitis, Mallory–Weiss tear, peptic ulcer disease, and bezoar formation, can develop.1, 5, 6
This article systematically reviews our current understanding of the epidemiology, basic science, etiology, and pathophysiology of gastroparesis. It also reviews recent advances in management, including patient evaluation, diagnosis, and treatment.
Section snippets
Epidemiology
The epidemiology of gastroparesis in the USA is not well-defined, but the condition is relatively common. A population-based study in Olmsted County, Minnesota identified 3604 potential cases, of which 83 met diagnostic criteria for definite gastroparesis.7 The age-adjusted incidence per 100,000 person-years for definite gastroparesis was 2.5 for men and 9.8 for women, while the age-adjusted prevalence per 100,000 persons was 9.6 for men and 37.8 for women.7 These statistics also support the
Basic Science
The stomach is traditionally described as having 2 functional segments—the fundus and antrum.3 Both participate in differing but complementary roles in gastric emptying. Although discrepancies exist, general opinion is that the fundus is more responsible for the gastric emptying of liquids, while the antrum is a greater contributor in the gastric emptying of solids.17, 18 During a meal, the fundus serves as a reservoir and facilitates the chemical digestion of food into large particles via
Etiology and Pathophysiology
Underlying conditions should be considered in patients who develop a gastrointestinal motility disorder. Of 146 patients, the most common etiologies of gastroparesis were idiopathic (36%), diabetic (29%), and postgastric surgery (13%); other associated disorders included Parkinson's disease, collagen vascular disorders, and intestinal pseudoobstruction.4
Idiopathic gastroparesis is an umbrella term used when no known cause can be identified. Postinfectious or postviral gastroparesis is regarded
History and Physical Examination
Careful history taking and an understanding of the patient's symptoms can help discern other disorders before making a preliminary diagnosis. Several conditions can mimic the clinical presentation of gastroparesis, including esophagitis, peptic ulcer disease, malignancy, bowel obstruction, and pancreaticobiliary disorders.5 Medication side effects and uremia should be considered as well.5
Patients suspected of gastroparesis usually present with several concurrent but nonspecific abdominal
Diagnostic Tests and Imaging
Initial laboratory testing is generally not useful in diagnosing patients with presumed gastroparesis, but routine blood tests should be tailored toward the outcome of the history and physical examination. They can also be performed to rule out other differentials. For example, pancreatitis should be considered in patients presenting with abdominal pain in the epigastric region, and a serum lipase would be most helpful. When other conditions are ruled out, then gastroparesis should be given
General Approach
General principles for patient management include (1) hydration with correction of electrolyte imbalances; (2) identification and treatment of the underlying disorder (ie, diabetes mellitus); and (3) alleviation of symptoms (ie, nausea, vomiting) with medications.84 A list of the patient's current medications should be reviewed, and those that may precipitate gastric dysmotility or limit the advantages of antiemetics and prokinetic agents should be discontinued.1 Diabetics with symptoms of
Future Direction
There has been considerable progress in the management of gastroparesis over the last 5 years, and overall, the outlook is encouraging (Fig 7).129
Advances in our understanding of the pathophysiology have led to the development of potentially useful new medications. The etiology of diabetic gastroparesis is multifactorial and has not been completely elucidated yet. Induction of the heme oxygenase-1 pathway has been shown previously to counter cellular changes related to the gastrointestinal
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Competing Interests. The authors declare no conflict of interest and have no financial disclosures to make. This manuscript has not been published previously and is not under consideration in another journal.