Gastroparesis


  • Postprandial nausea
  • Vomiting
  • Early satiety
  • Epigastric pain
  • Fullness
  • Bloating
  • Weight loss
  • Succussion splash
Diagnostic Test
  • CBC
  • CMP:
    • Serum glucose, creatinine, potassium, total protein, Albumin
  • Serum amylase and lipase
  • Pregnancy test
  • Abdominal x-ray
  • Endoscopy
  • contrast radiography
  • gastric emptying scintigraphy
  • nondigestible capsule test

Emerging Tests

  • 13C-labeled octanoic acid breath tes
Management
Pt Group Tx Line Treatment
Acute symptoms 1st Prokinetic agent
Metoclopramide is both a dopamine receptor antagonist and a serotonin receptor agonist. It is better for short-term treatment and is known to improve gastrointestinal symptoms and gastric emptying. It also has antiemetic properties. It should be used for up to 5 days only in order to minimize the risk of neurologic and other adverse effects. Its use in the long-term treatment of gastroparesis is no longer recommended. It should be noted that the US Food and Drug Administration (FDA) has not endorsed this alert or released a similar drug safety alert for the drug at this stage.

Primary Options:
Erythromycin ethylsuccinate : 100 mg intravenously every 8 hours
Metoclopramide : 10 mg orally/intravenously three times daily for a maximum of 5 days, maximum 30 mg/day
 
Plus Antiemetic
Tricyclic antidepressants (e.g., amitriptyline, nortriptyline): have some antiemetic properties and have a role in refractory gastroparesis. 
5-HT3 antagonists (e.g., ondansetron): effective in the treatment of chemotherapy-induced vomiting, radiation therapy-induced vomiting, and postoperative vomiting. Routine use of this class of medications is not recommended in gastroparesis given its prohibitive cost, although it is given if all other antiemetics have failed to control symptoms.

Primary Options
Promethazine : 12.5 to 25 mg intravenously/intramuscularly every 4-6 hours when required
Prochlorperazine maleate : 10 mg intravenously/intramuscularly every 6 hours when required

Secondary Options

Ondansetron : 4 mg intravenously every 8 hours
Amitriptyline : 10-25 mg orally once daily at bedtime
Nortriptyline : 10-25 mg orally once daily at bedtime
 
Plus Dietary advice
Patients are usually intolerant to certain types of foods, such as dairy products and red meat, which can be avoided. Other dietary interventions that could help are: small, frequent (4-6/day) meals; low insoluble and indigestible fiber in diet as this slows down gastric emptying and promotes the formation of bezoars; consuming a low-fat diet; changing the diet to a high-calorie liquid diet or blenderized meals.
 
Adjunct Opioid analgesic
Many patients do not respond to conservative measures and need intermittent or chronic administration of opioid analgesics.
Tramadol could be tried initially as it has lower incidence of gastrointestinal adverse effects than other opioids. Methadone and fentanyl transdermal patches cause less constipation than other opioids, and may be used if pain is not improved with tramadol under the guidance of a pain management specialist. 
Referral to a pain management consultant is a reasonable intervention for patients not responding to conservative measures.

Primary Options
Tramadol : 50-100 mg orally (immediate-release) every 4-6 hours when required, maximum 400 mg/day

Secondary Options
Methadone : 2.5 to 10 mg orally every 8-12 hours when required, adjust according to response; doses of 5-20 mg orally every 6-8 hours have also been used
Fentanyl transdermal : 12 microgram/hour patch every 72 hours
 
Adjunct IV Fluids
Dehydration and electrolyte abnormalities can be corrected by intravenous administration of fluid and the appropriate electrolyte (e.g., potassium).
 
Adjunct Glycemic control
Blood sugar levels of 288 to 360 mg/dL (upper limit of normal is 105 mg/dL) can cause delayed emptying of both solids and liquids. Therefore, efforts to intensify glycemic control and maintain a euglycemic state are highly recommended.