Elsevier

Disease-a-Month

Volume 57, Issue 2, February 2011, Pages 74-101
Disease-a-Month

Gastroparesis: Approach, Diagnostic Evaluation, and Management

https://doi.org/10.1016/j.disamonth.2010.12.007Get rights and content

Gastroparesis is a chronic motility disorder of the stomach that involves delayed emptying of solids and liquids, without evidence of mechanical obstruction. Although no cause can be determined for the majority of cases, the disease often develops as a complication of abdominal surgeries or because of other underlying disorders, such as diabetes mellitus or scleroderma. The pathophysiology behind delayed gastric emptying is still not well-understood, but encompasses abnormalities at 3 levels—autonomic nervous system, smooth muscle cells, and enteric neurons. Patients will often cite nausea, vomiting, postprandial fullness, and early satiety as their most bothersome symptoms on history and physical examination. Those that present with severe disease may already have developed complications, such as the formation of bezoars or masses of undigested food. In patients suspected of gastroparesis, diagnostic evaluation requires an initial upper endoscopy to rule out mechanical causes, followed by a gastric-emptying scintigraphy for diagnosis. Other diagnostic alternatives would be wireless capsule motility, antroduodenal manometry, and breath testing. Once gastroparesis is diagnosed, dietary modifications, such as the recommendation of more frequent and more liquid-based meals, are encouraged. Promotility medications like erythromycin and antiemetics like prochlorperazine are offered for symptomatic relief. These agents may be frequently changed, as the right combination of effective medications will vary with each individual. In patients who are refractory to pharmacologic treatment, more invasive options, such as intrapyloric botulinum toxin injections, placement of a jejunostomy tube, or implantation of a gastric stimulator, are considered. Future areas of research are based on current findings from clinical studies. New medications, such as hemin therapy, are emerging because of a better understanding of the pathophysiology behind gastroparesis, and present treatment options, such as gastric electric stimulation, are evolving to be more effective. Regenerative medicine and stem cell-based therapies also hold promise for gastroparesis in the near future.

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.

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