Gastroparesis is defined as a symptomatic disorder of the stomach characterized by delayed gastric emptying and an absence of mechanical obstruction.1,2 The prevalence of people diagnosed with this disorder is estimated to be around 25 per 100,000 people. However, many more people in the population have undiagnosed gastroparesis and are unaware of the signs and symptoms of this disorder.

  1. Gastroparesis can cause a variety of gastrointestinal symptoms. Symptoms of gastroparesis include nausea, vomiting, early satiety, post-prandial fullness, bloating, and upper abdominal pain.3

  2. There are three main causes of gastroparesis. The most common causes of gastroparesis are diabetes, post-surgical, and idiopathic. Diabetes and idiopathic account for more than 60 percent of the known cases, with diabetes mellitus causing an estimated 25 percent of cases. Other causes of gastroparesis include connective tissue and autoimmune disorders, ischemia, and medications that can slow gastric emptying. These medications include opioid narcotics, newer diabetic medications, anti-depressants, anti-cholinergics, and anti-hypertensives. Diagnosis of gastroparesis in children is often overlooked, but most cases of pediatric gastroparesis are secondary to viral illness or surgical intervention.1,4–7

  3. The main diagnostic test for gastroparesis is gastric-emptying scintigraphy (GES). GES involves the patient ingesting a radiolabeled meal, often eggs, which contains imaging at different time points to evaluate gastric retention. Upper endoscopy is also performed during work up to eliminate mechanical (obstructive) causes. Breath testing, wireless capsule motility, and antro-duodenal motility are other less common alternatives to use to diagnose gastroparesis. Breath testing is a noninvasive method that can be used in the outpatient setting which involves mixing a 13C isotype bound to a digestible substance, octanoic acid, with a solid meal. After ingestion, the metabolism of 13C-CO2 can be measured from exhalation in the lungs. This test is beneficial due to the lack of ionizing radiation, but it has limitations due to excluding patients with celiac disease and lactose intolerance.8,9

  4. Gastroparesis is found to be more common in women than men, and although rare, can present in childhood. A recent large population-based study was completed on gastroparesis, and the age-adjusted incidence for definite gastroparesis in men was 2.4 per 100,000 person-years while it was 9.8 per 100,000 person-years in women. Additionally, the prevalence of definitive gastroparesis was found to be 9.6 per 100,000 person-years in men and 38 per 100,000 person-years in women. In children, the reported cases of gastroparesis are more equally divided across both genders, with male children and female adolescents having a slight majority of cases. Abdominal pain, nausea and bloating are less commonly reported symptoms by children and adolescents whereas early satiety and weight loss are often noticed. Premature infants often present with delayed gastric emptying and emptying gradually improves with age (usually by 32 weeks gestation).7,10,11

  5. The Gastroparesis Cardinal Symptoms Index (GCSI) was developed to evaluate the severity of patients’ symptoms. The GCSI is broken down into three categories titled nausea/vomiting, post-prandial fullness/early satiety, and bloating.12 Each criterion is rated 0-5 by patient, with 0 representing no symptoms and 5 representing very severe symptoms. The nausea/vomiting category has three criteria: nausea, retching, and vomiting. The post-prandial fullness/early satiety category has four criteria: stomach fullness, inability to finish meal, fullness after eating, and loss of appetite. Bloating category has two criteria: bloating and belly visibly larger. Monitoring patient’s GCSI scores can help determine if symptoms are improving/worsening over time.

  6. There are important differential diagnoses that cause chronic nausea and vomiting that are key to rule out in the diagnosis of gastroparesis. Many psychiatric diseases such as depression and eating disorders can manifest clinical symptoms of gastroparesis. Rumination syndrome characterizes daily regurgitation of food that has not yet been digested soon after eating, yet these patients have normal gastric emptying. Functional dyspepsia includes an overlap of the symptoms of early feelings of fullness and bloating, yet the dyspepsia patients often have normal emptying, with only 1/3 of patients having slow emptying.13

  7. Metoclopramide is currently the only FDA approved medication to treat gastroparesis. Metoclopramide is a dopamine D2-receptor antagonist. Dopamine has a relaxant effect on the GI tract. Occasionally, the medication is administered intranasally versus orally due to some patients’ severe nausea and vomiting. Common side effects can include an adverse sense of taste, headache, and fatigue. With long-term use of metoclopramide, there is a greater risk for developing tardive dyskinesia and Parkinson-like syndrome. Metoclopramide is not FDA approved for use in children; however, it is still commonly used in management. Multiple trials are in process that are studying the risks and benefits of metoclopramide use in children. Due to these potential side effects, dietary modification in both children and adults is usually attempted first. Eating multiple, small meals a day that are low in fat and fiber is recommended due to fats and fibers contributing to delayed gastric emptying. Patients are also advised to avoid carbonated beverages and remain well-hydrated. Additionally, liquid diets are often well tolerated as gastroparesis usually affects the gastric emptying of solids > liquids. If liquids are not tolerable, enteral nutrition is sometimes necessary to avoid a caloric deficit. Medication and diet should be trialed on patients before endoscopic/surgical intervention is considered; however, many patients cannot tolerate metoclopramide. Anti-emetics are used to treat symptoms of nausea/vomiting (odansetron, promethazine, scopolamine). Promethazine is only approved for use by the FDA in children over the age of 2. The FDA recommends using the drug with caution and at the lowest dose possible due to cases of respiratory depression and death. Hyperglycemia can often exacerbate delays in gastric emptying, so maintaining glycemic can be helpful in minimizing symptoms. Other drugs for gastroparesis are in clinical trial stages, but none have proven effective enough to be FDA approved.3,7,14

  8. There are endoscopic and surgical options for treatment of gastroparesis. Around 30 percent of patients with gastroparesis fail to achieve relief of symptoms with less invasive forms of treatment such as diet modification and medication. For these patients, endoscopic and surgical options should be discussed. Endoscopic options include: injection of botulinum toxin (botox) into the pylorus and G-POEM (endoscopic pyloroplasty). Surgical options include implantation of gastric stimulator, surgical pyloroplasty, and subtotal gastrectomy.

  9. Enterra Therapy with an electric gastric stimulator is an approved therapy to mechanically stimulate the stomach. The device can be inserted via open technique or laparoscopically. In the procedure, two leads are connected to the greater curvature of the stomach around 10 cm from the pylorus, and the other sides of the leads are connected to the neurostimulator. The stimulator is sutured subcutaneously into the abdominal wall, and baseline parameters for the device are set.15 The device is able to be reprogrammed in the clinic periodically based on each patient’s needs.

  10. There are some adjuncts to therapy that should be considered in patients not doing well and losing a significant amount of weight. Patients with gastroparesis respond well to one time dose of haloperidol in the ER. One time dose of haloperidol was found to significantly reduce the need for admission and opiates within the ER. Patients who have significant GI losses should be considered for home IVF/TPN therapy or enteral nutrition via feeding tube. Having supplemental fluids or nutrition at home can decrease need for hospitalizations.