Gastroparesis

By: Frank Friedenberg, M.D. and Henry Parkman, M.D., Temple University School of Medicine, Philadelphia, PA

Gastroparesis is a disorder in which the stomach empties very slowly. The delay in stomach emptying can result in bothersome symptoms that interfere with a patient's life. Gastroparesis most often occurs when the nerves to the stomach are damaged or don't work properly. Diabetes is the most common cause of gastroparesis. Gastroparesis can also occur after stomach surgery for other conditions. Other causes of gastroparesis include Parkinson's disease and some medications, especially narcotic pain medications. In many patients a cause of the gastroparesis cannot be found and the disorder is termed idiopathic gastroparesis. Over the last several years, as more is being found out about gastroparesis, it has become clear this condition affects many people and the condition can cause a wide range of symptoms of differing severity.

Symptoms of Gastroparesis

The symptoms of gastroparesis most often occur during and after eating a meal. Symptoms may include:  

• Feeling of fullness after only a few bites of food
• Nausea and/or vomiting
• Vague stomach pain
• Weight loss due to a decreased appetite

Symptoms of gastroparesis may range from none to severe. A person with diabetic gastroparesis may have episodes of high and low blood sugar levels due to the unpredictable emptying of food from the stomach. Gastroparesis may be suspected in a person with diabetes who has blood sugar levels that become increasingly difficult to control.

Tests for Gastroparesis

The diagnosis of gastroparesis is confirmed with two types of tests. The first test is performed to make sure there is not an ulcer or an obstruction. This test could be an upper endoscopy where the doctor looks into the stomach with a flexible scope. Alternatively, this test could be an upper gastrointestinal series in which the patient drinks barium that outlines the stomach on an x-ray. The second test is one that actually measures how quickly food leaves the stomach. Most commonly, this test is a radioisotope gastric emptying scan. For this test, one eats food containing a small amount of a radioactive substance. The radioactivity in the body and particularly in the stomach can be imaged, allowing a doctor to see how quickly the meal leaves the stomach.

Treatment of Symptoms

Treatment of gastroparesis depends on the severity of the symptoms. Dietary changes may be helpful and include eating several small meals each day rather than three large meals. The meals should be low in fiber, fat, and roughage. Liquids are often better handled than solid food in patients with gastroparesis. For diabetic patients, controlling blood sugar levels may decrease symptoms of gastroparesis. [Ask your doctor or a registered dietician for dietary guidelines.]

Symptoms of gastroparesis may improve with treatment using medications prescribed by a doctor. When considering any medication, let your doctor know about all other drugs or supplements you are taking, both prescription and over-the-counter.

Some medications help the stomach empty more quickly (pro-motility agents). One pro-motility agent is metoclopramide (Reglan), although this drug is often associated with side effects that limit its use. Be sure to talk to your doctor about alternative treatments and known risks as well as the intended benefit if considering treatment with Reglan. With any drug it is important to be aware of the risks and expected benefit, understand how to recognize possible side effects, and know what to do if side effects occur.

Erythromycin is an antibiotic that can also speed up stomach emptying. Another pro-motility agent, domperidone, has been used in countries outside of the U.S to treat gastroparesis. While not approved by the Food and Drug Administration (FDA) in the U.S., if needed, domperidone can now be obtained through a doctor by special arrangements from the FDA.

Another treatment approach for gastroparesis is to use medications which decrease symptoms of nausea and vomiting (antiemetic agents). These agents include prochlorperazine (Compazine) and trimethobenzamide (Tigan).

In very severe cases of gastroparesis, generally with weight loss, a feeding tube is placed in the small intestine to provide nutrition in a way that avoids the stomach.

Newer treatments that are still being evaluated include injection of botulinum toxin (Botox) into the pylorus muscle at the end of the stomach where contents pass into the small intestine. This can relax the pylorus and increase stomach emptying. Gastric electric stimulation using a pacemaker (a surgically implanted battery operated device) on the stomach may be used in some cases where all types of medications fail to adequately control the symptoms of nausea and vomiting.

Persons who experience symptoms of gastroparesis should talk to their doctor to find out what is wrong. If gastroparesis is diagnosed, the doctor can work with the patient to develop a treatment plan best suited for individual circumstances.

  

 © Copyright 2006 IFFGD. All Rights Reserved.

 

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Gastroparesis and Diabetes
Source: NIH Publication No. 04-4348 December 2003.

 

What is gastroparesis?
Gastroparesis, also called delayed gastric emptying, is a disorder in which the stomach takes too long to empty its contents. It often occurs in people with type 1 diabetes or type 2 diabetes. [Note: Gastroparesis can also occur from other causes, and sometimes the underlying cause is not known; this is called idiopathic gastroparesis.]

Gastroparesis happens when nerves to the stomach are damaged or stop working. The vagus nerve controls the movement of food through the digestive tract. If the vagus nerve is damaged, the muscles of the stomach and intestines do not work normally, and the movement of food is slowed or stopped.

Diabetes can damage the vagus nerve if blood glucose levels remain high over a long period of time. High blood glucose causes chemical changes in nerves and damages the blood vessels that carry oxygen and nutrients to the nerves. 

Signs and symptoms of gastroparesis are   

• Heartburn
• Nausea
• Vomiting of undigested food
• An early feeling of fullness when eating
• Weight loss
• Abdominal bloating
• Erratic blood glucose levels
• Lack of appetite
• Gastroesophageal reflux 
• Spasms of the stomach wall 

These symptoms may be mild or severe, depending on the person.

Complications of Gastroparesis
If food lingers too long in the stomach, it can cause problems like bacterial overgrowth from the fermentation of food. Also, the food can harden into solid masses called bezoars that may cause nausea, vomiting, and obstruction in the stomach. Bezoars can be dangerous if they block the passage of food into the small intestine.

Gastroparesis can make diabetes worse by adding to the difficulty of controlling blood glucose. When food that has been delayed in the stomach finally enters the small intestine and is absorbed, blood glucose levels rise. Since gastroparesis makes stomach emptying unpredictable, a person's blood glucose levels can be erratic and difficult to control.

Major Causes of Gastroparesis 
Gastroparesis is most often caused by  

• Diabetes
• Postviral syndromes
• Anorexia nervosa
• Surgery on the stomach or vagus nerve
• Medications, particularly anticholinergics and narcotics (drugs that slow contractions in the intestine)
• Gastroesophageal reflux disease (rarely)
• Smooth muscle disorders such as amyloidosis and scleroderma
• Nervous system diseases, including abdominal migraine and Parkinson's disease
• Metabolic disorders, including hypothyroidism

Diagnosis
The diagnosis of gastroparesis is confirmed through one or more of the following tests.   

• Barium x ray. After fasting for 12 hours, you will drink a thick liquid called barium, which coats the inside of the stomach, making it show up on the x ray. Normally, the stomach will be empty of all food after 12 hours of fasting. If the x ray shows food in the stomach, gastroparesis is likely. If the x ray shows an empty stomach but the doctor still suspects that you have delayed emptying, you may need to repeat the test another day. On any one day, a person with gastroparesis may digest a meal normally, giving a falsely normal test result. If you have diabetes, your doctor may have special instructions about fasting.
• Barium beefsteak meal. You will eat a meal that contains barium, thus allowing the radiologist to watch your stomach as it digests the meal. The amount of time it takes for the barium meal to be digested and leave the stomach gives the doctor an idea of how well the stomach is working. This test can help detect emptying problems that do not show up on the liquid barium x ray. In fact, people who have diabetes-related gastroparesis often digest fluid normally, so the barium beefsteak meal can be more useful.
• Radioisotope gastric-emptying scan. You will eat food that contains a radioisotope, a slightly radioactive substance that will show up on the scan. The dose of radiation from the radioisotope is small and not dangerous. After eating, you will lie under a machine that detects the radioisotope and shows an image of the food in the stomach and how quickly it leaves the stomach. Gastroparesis is diagnosed if more than half of the food remains in the stomach after 2 hours.
• Gastric manometry. This test measures electrical and muscular activity in the stomach. The doctor passes a thin tube down the throat into the stomach. The tube contains a wire that takes measurements of the stomach's electrical and muscular activity as it digests liquids and solid food. The measurements show how the stomach is working and whether there is any delay in digestion.
• Blood tests. The doctor may also order laboratory tests to check blood counts and to measure chemical and electrolyte levels.

To rule out causes of gastroparesis other than diabetes, the doctor may do an upper endoscopy or an ultrasound.

Treatment
The primary treatment goal for gastroparesis related to diabetes is to regain control of blood glucose levels. Treatments include insulin, oral medications, changes in what and when you eat, and, in severe cases, feeding tubes and intravenous feeding.

• Upper endoscopy. After giving you a sedative, the doctor passes a long, thin tube called an endoscope through the mouth and gently guides it down the esophagus into the stomach. Through the endoscope, the doctor can look at the lining of the stomach to check for any abnormalities.
• Ultrasound. To rule out gallbladder disease or pancreatitis as a source of the problem, you may have an ultrasound test, which uses harmless sound waves to outline and define the shape of the gallbladder and pancreas.

It is important to note that in most cases treatment does not cure gastroparesis--it is usually a chronic condition. Treatment helps you manage the condition so that you can be as healthy and comfortable as possible.

Insulin for blood glucose control
If you have gastroparesis, your food is being absorbed more slowly and at unpredictable times. To control blood glucose, you may need to

Your doctor will give you specific instructions based on your particular needs.

• Take insulin more often
• Take your insulin after you eat instead of before
• Check your blood glucose levels frequently after you eat and administer insulin whenever necessary  

Medication Several drugs are used to treat gastroparesis. Your doctor may try different drugs or combinations of drugs to find the most effective treatment.

More about Domperidone: In 2004 the FDA determined that there are some patients with severe gastrointestinal disorders, such as severe gastroparesis or severe GI motility disorders that are refractory (resistant) to standard therapy, who may benefit from domperidone and in whom the drug's benefits outweigh its risks. FDA encourages physicians who would like to prescribe domperidone for their patients with severe gastrointestinal disorders that are refractory to standard therapy to open an Investigational New Drug Application (IND). Find out more at this FDA web page.

• Metoclopramide (Reglan). This drug stimulates stomach muscle contractions to help empty food. It also helps reduce nausea and vomiting. Metoclopramide is taken 20 to 30 minutes before meals and at bedtime. Side effects of this drug are fatigue, sleepiness, and sometimes depression, anxiety, and problems with physical movement.
• Erythromycin. This antibiotic also improves stomach emptying. It works by increasing the contractions that move food through the stomach. Side effects are nausea, vomiting, and abdominal cramps.
• Domperidone. The Food and Drug Administration is reviewing domperidone, which has been used elsewhere in the world to treat gastroparesis. It is a promotility agent like metoclopramide. Domperidone also helps with nausea.
• Other medications. Other medications may be used to treat symptoms and problems related to gastroparesis. For example, an antiemetic can help with nausea and vomiting. Antibiotics will clear up a bacterial infection. If you have a bezoar, the doctor may use an endoscope to inject medication that will dissolve it.  

Meal and Food Changes
Changing your eating habits can help control gastroparesis. Your doctor or dietitian will give you specific instructions, but you may be asked to eat six small meals a day instead of three large ones. If less food enters the stomach each time you eat, it may not become overly full. Or the doctor or dietitian may suggest that you try several liquid meals a day until your blood glucose levels are stable and the gastroparesis is corrected. Liquid meals provide all the nutrients found in solid foods, but can pass through the stomach more easily and quickly.

The doctor may also recommend that you avoid high-fat and high-fiber foods. Fat naturally slows digestion--a problem you do not need if you have gastroparesis--and fiber is difficult to digest. Some high-fiber foods like oranges and broccoli contain material that cannot be digested. Avoid these foods because the indigestible part will remain in the stomach too long and possibly form bezoars.

Feeding Tube
If other approaches do not work, you may need surgery to insert a feeding tube. The tube, called a jejunostomy tube, is inserted through the skin on your abdomen into the small intestine. The feeding tube allows you to put nutrients directly into the small intestine, bypassing the stomach altogether. You will receive special liquid food to use with the tube. A jejunostomy is particularly useful when gastroparesis prevents the nutrients and medication necessary to regulate blood glucose levels from reaching the bloodstream. By avoiding the source of the problem--the stomach--and putting nutrients and medication directly into the small intestine, you ensure that these products are digested and delivered to your bloodstream quickly. A jejunostomy tube can be temporary and is used only if necessary when gastroparesis is severe.

Parenteral Nutrition
Parenteral nutrition refers to delivering nutrients directly into the bloodstream, bypassing the digestive system. The doctor places a thin tube called a catheter in a chest vein, leaving an opening to it outside the skin. For feeding, you attach a bag containing liquid nutrients or medication to the catheter. The fluid enters your bloodstream through the vein. Your doctor will tell you what type of liquid nutrition to use.

This approach is an alternative to the jejunostomy tube and is usually a temporary method to get you through a difficult spell of gastroparesis. Parenteral nutrition is used only when gastroparesis is severe and is not helped by other methods.

New Treatments
A gastric neurostimulator has been developed to assist people with gastroparesis. The battery-operated device is surgically implanted and emits mild electrical pulses that help control nausea and vomiting associated with gastroparesis. This option is available to people whose nausea and vomiting do not improve with medications.

The use of botulinum toxin has been shown to improve stomach emptying and the symptoms of gastroparesis by decreasing the prolonged contractions of the muscle between the stomach and the small intestine (pyloric sphincter). The toxin is injected into the pyloric sphincter.

Points to Remember

• Gastroparesis may occur in people with type 1 diabetes or type 2 diabetes [and may occur from other causes or unknown (idiopathic) causes].
• Gastroparesis is the result of damage to the vagus nerve, which controls the movement of food through the digestive system. Instead of the food moving through the digestive tract normally, it is retained in the stomach.
• The vagus nerve becomes damaged after years of poor blood glucose control, resulting in gastroparesis. In turn, gastroparesis contributes to poor blood glucose control.
• Symptoms of gastroparesis include early fullness, nausea, vomiting, and weight loss.
• Gastroparesis is diagnosed through tests such as x rays, manometry, and scanning.
• Treatments include changes in when and what you eat, changes in insulin type and timing of injections, oral medications, a jejunostomy, parenteral nutrition, gastric neurostimulators, or botulinum toxin.  

Hope Through Research
The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Division of Digestive Diseases and Nutrition supports basic and clinical research into gastrointestinal motility disorders, including gastroparesis. Among other areas, researchers are studying whether experimental medications can relieve or reduce symptoms of gastroparesis, such as bloating, abdominal pain, nausea, and vomiting, or shorten the time needed by the stomach to empty its contents following a standard meal.

The U.S. Government does not endorse or favor any specific commercial product or company. Trade, proprietary, or company names appearing in this document are used only because they are considered necessary in the context of the information provided. If a product is not mentioned, this does not mean or imply that the product is unsatisfactory.

This NIH Publication is not copyrighted.