Stomach: Gastric Emptying Diseases

Gastroparesis (Delayed Gastric Emptying)

Definition

  • Delayed Emptying of Solids in the Absence of Mechanical Obstruction

Causes

  • Idiopathic – Most Common Cause
  • Diabetes – Most Common Non-Idiopathic Cause
  • Medications (Narcotics, CCB, Octreotide, Clonidine, etc.)
  • Viral
  • Postoperative Vagal Injury
  • Scleroderma
  • Neurologic Disease (Multiple Sclerosis, CVA, Parkinson’s Disease)

Presentation

  • Most Common in Women
  • Sx: Bloating, Pain, Nausea, Vomiting & Early Satiety

Diagnosis

  • First: EGD to Rule Out Malignancy
  • Then: Gastric Emptying Study
    • ≥ 60% Retention at 2 Hours
    • ≥ 10% Retention at 4 Hours
  • Severity:
    • Mild: 10-15% at 4 Hours
    • Moderate: 15-35% at 4 Hours
    • Severe: > 35% at 4 Hours

Treatment

  • Acute Exacerbation Tx: Reglan or Erythromycin
  • Chronic Tx: Dietary Changes (Multiple Small Meals with Low-Fat & Low-Fiber)
    • If Fails: Reglan, Domperidone or Erythromycin
  • Options if Fails:
    • Venting Gastrostomy
    • Pyloroplasty
    • Gastric Electrical Stimulation/Pacemaker

Normal Gastric Emptying Study 1

Delayed Gastric Emptying; 22% at 4 Hours 2

Dumping Syndrome (Rapid Gastric Emptying)

Definition

  • Rapid Emptying of Hyperosmolar Chyme (Especially Carbohydrates) into the Small Bowel

Phases

  • Early (20-30 Minutes)
    • Cause: Abrupt Fluid Shift into Bowel
      • Release of Vasoactive Agents (Neurotensin & VIP) Incretins (GLP-1) & Glucose-Modulating Hormones
    • Sx: GI Symptoms & Vasomotor Symptoms
      • GI Symptoms: Nausea, Vomiting, Diarrhea, Pain & Bloating
      • Vasomotor Symptoms: Diaphoresis, Palpitations, Flushing & Syncope
  • Late (1-3 Hours)
    • Cause: Reactive Exaggerated Insulin Increase
      • From Rapid Glucose Absorption & Increased Incretin (GLP-1 & GIP) Release
    • Sx: Hypoglycemia & Autonomic/CV Side Effects

Causes

  • Surgery (Most Common)
    • Gastrectomy – Roux-en-Y Lower Risk Than Billroth Reconstructions
      • Highest Risk: Billroth II
    • Gastric Bypass
    • Esophagectomy
    • Vagotomy or Pyloroplasty
  • Ulcers

Diagnosis

  • Dx: Gastric Emptying Study

Treatment

  • Primary Tx: Dietary Changes
    • Frequent Small Meals
    • High in Fiber & Protein
    • Low in Carbs & Sugar
  • If Refractory or Severe: Octreotide (The Most Effective Treatment)
  • If Fails with Prior Distal Gastrectomy: Surgical Conversion to Roux-en-Y Reconstruction

Pathophysiology of Dumping Syndrome 3

References

  1. Vasavid P, Chaiwatanarat T, Pusuwan P, Sritara C, Roysri K, Namwongprom S, Kuanrakcharoen P, Premprabha T, Chunlertrith K, Thongsawat S, Sirinthornpunya S, Ovartlarnporn B, Kachintorn U, Leelakusolvong S, Kositchaiwat C, Chakkaphak S, Gonlachanvit S. Normal Solid Gastric Emptying Values Measured by Scintigraphy Using Asian-style Meal:A Multicenter Study in Healthy Volunteers. J Neurogastroenterol Motil. 2014 Jul 31;20(3):371-8. (License: CC BY-NC-3.0)
  2. Shin YK, Kwon JG, Kim KY, Park JB, Han SJ, Cheon JW, Kim EY, Kim HG, Lee TS, Park KS, Won KS. A case of cyclic vomiting syndrome responding to gonadotropin-releasing hormone analogue. J Neurogastroenterol Motil. 2010 Jan;16(1):77-82. (License: CC BY-NC-3.0)
  3. Narayanan RP, Syed AA. Pregnancy Following Bariatric Surgery-Medical Complications and Management. Obes Surg. 2016 Oct;26(10):2523-9. (License: CC BY-4.0)