3. Gastroparesis

 

 

Overview

  • Gastroparesis is a chronic motility disorder characterized by delayed gastric emptying in the absence of mechanical obstruction.
  • Commonly associated with type 1 and type 2 diabetes mellitus, but can also occur following acute viral illness or post-surgical complications.

Epidemiology

  • More common in females (~80% of cases).
  • Diabetic gastroparesis accounts for 30–40% of cases.
  • Idiopathic gastroparesis accounts for 36% of cases.

Pathophysiology

  • Dysfunction in the enteric nervous system or vagus nerve.
  • Loss of coordination between gastric contractions and pyloric relaxation.
  • In diabetic gastroparesis: chronic hyperglycemia leads to vagal neuropathy and delayed gastric emptying.

Clinical Features

  • Early satiety.
  • Nausea and vomiting.
  • Abdominal bloating and pain.
  • Postprandial fullness.
  • Weight loss in severe cases.

Diagnosis

Diagnostic Criteria:

  1. Gastric emptying scintigraphy:
    • Gold standard for diagnosis.
    • Abnormal if >10% of the radio-labelled meal remains in the stomach after 4 hours. In severe cases >35 % indicates
  2. Alternative tests:
    • 13C-octanoic acid breath test (non-invasive alternative).
    • Wireless motility capsule: Measures pH, pressure, and temperature along the GI tract.
    • Upper GI endoscopy: To exclude mechanical obstruction.

Differential Diagnosis

  • Mechanical gastric outlet obstruction (e.g., gastric cancer, peptic ulcer disease).
  • Chronic intestinal pseudo-obstruction.
  • Functional dyspepsia.

Management (Based on UK and European Guidelines)

Lifestyle Modifications

  1. Dietary Adjustments:
    • Small, frequent meals (low-fat, low-fiber meals).
    • Nutritional support (oral supplements, enteral feeding if severe).
  2. Glycemic Control:
    • Tight blood glucose control in diabetic patients to reduce gastroparesis progression.

Pharmacological Therapy

  1. Prokinetic Agents:
    • Metoclopramide: Dopamine receptor antagonist.
      • Dose: 10 mg up to 3 times daily before meals.
      • Caution: Risk of extrapyramidal side effects and tardive dyskinesia.
    • Domperidone: Peripheral dopamine antagonist.
      • Dose: 10–20 mg three times daily.
      • Fewer central nervous system side effects than metoclopramide.
      • Requires ECG monitoring due to potential QT prolongation.
    • Erythromycin: Macrolide antibiotic with motilin receptor agonist properties.
      • Dose: 125–250 mg three times daily.
      • Short-term use due to tachyphylaxis (reduced efficacy over time).
  2. Antiemetics:
    • Used to control nausea and vomiting (e.g., ondansetron).

Advanced Interventions

  1. Gastric Electrical Stimulation (GES):
    • Indicated for refractory cases with severe symptoms.
    • Procedure:
      • High-frequency, low-energy electrical stimulation delivered 10 cm proximal to the pylorus.
      • Aimed at reducing nausea and vomiting rather than directly improving gastric emptying.
    • Studies show symptom improvement in select patients.
  2. Endoscopic or Surgical Options:
    • Pyloromyotomy (G-POEM): Endoscopic or surgical division of pyloric muscle to enhance gastric emptying.
    • Jejunostomy feeding tube: Considered in cases with significant nutritional deficits.

Monitoring and Follow-up

  • Regular assessment of nutritional status and symptom control.
  • Monitor for medication side effects (e.g., ECG for domperidone).
  • Evaluate glucose levels in diabetic gastroparesis.

Prognosis

  • Chronic and relapsing disorder.
  • Early diagnosis and multimodal management improve quality of life and prevent complications.

Complications

  • Malnutrition and dehydration.
  • Bezoar formation (solid mass of undigested food).
  • Significant impact on glycemic control in diabetic patients.

Visual Aids

Table: Prokinetic Agents for Gastroparesis

Drug

Mechanism of Action

Dose

Key Considerations

Metoclopramide

D2 receptor antagonist

10 mg TDS

Risk of extrapyramidal side effects.

Domperidone

Peripheral D2 antagonist

10–20 mg TDS

QT prolongation—monitor ECG.

Erythromycin

Motilin receptor agonist

125–250 mg TDS

Short-term use due to tachyphylaxis.

 

References

  1. British Society of Gastroenterology (BSG) Guidelines.
  2. Camilleri M, et al. "Diabetic gastroparesis: A review." NEJM. 2018.
  3. European Society of Gastroenterology (ESGE) Guidelines.