Gastroparesis – Causes, Signs and symptoms, Treatment

Gastroparesis

Also called: Stomach Paralysis, Delayed Gastric Emptying, DGE

Summary

Gastroparesis is a condition in which food or liquid passes too slowly from the stomach into the small intestine. It is also called delayed gastric emptying or stomach paralysis, and often occurs in patients with type 1 or type 2 diabetes.

Gastroparesis is usually caused by damage to the vagus nerve, which controls the muscular contractions of the stomach. The vagus nerve can become damaged in many ways. The most common are having diabetes or undergoing surgery to the esophagus, stomach or duodenum. Other common causes include taking certain medications (e.g,  narcotic pain relievers) and having certain disorders (e.g., scleroderma, Parkinson’s disease).

The most common signs and symptoms of gastroparesis include nausea, vomiting and feeling full early into a meal. Symptoms may be mild or severe depending on the patient.

Gastroparesis is usually diagnosed by a physician during a physical examination that includes a complete medical history. A number of tests including a gastric emptying study, an upper GI barium test and an upper endoscopy, may be performed to help detect gastroparesis or identify other conditions that may be producing symptoms.

There is no cure for gastroparesis. Therefore, treatment typically focuses on managing the condition. Treatment may include making changes in diet or eating habits, such as eating smaller meals more frequently, avoiding foods with high levels of fat and/or fiber and taking nutritional supplements. It may also include taking medications, such as antiemetics or prokinetics. Severe cases of gastroparesis may require surgery. During surgery, the lower part of the stomach is stapled or bypassed and the remaining portion of the stomach is reconnected to the small intestine.

About gastroparesis

Gastroparesis is a disorder in which the stomach muscles function improperly, causing food and liquid to pass too slowly into the small intestine. It is also called delayed gastric emptying or stomach paralysis, and often occurs in patients with type 1 or type 2 diabetes. Diabetes is a disorder in the body’s ability to effectively produce or use the hormone insulin, which regulates blood sugar (glucose).

Gastropathy is a term used for milder cases that may be temporary and reversible. Gastroparesis is more severe and usually chronic. Gastropathy is more common than gastroparesis.

The stomach is a saclike organ located between the esophagus and the small intestine. It has three layers of muscles whose function is to crush food and mix it with enzymes and acids. After food enters the stomach, it is pulverized and propelled to the pyloric sphincter (the muscle between the stomach and the small intestine) by muscular contractions (peristalsis). The pyloric sphincter then pushes the food to the duodenum (the first part of the small intestine connected to the stomach).

The muscular contractions of the stomach are controlled by the vagus nerve (a nerve that originates in the brainstem and plays a role in both sensory and motor functions). The vagus nerve sends signals to the smooth muscles of the stomach, causing them to contract.

The vagus nerve can become damaged when blood sugar levels are elevated for a prolonged period of time, which is common in patients with diabetes. The vagus nerve can also become damaged during surgery to the esophagus, stomach or duodenum.

Under normal circumstances, about one-eighth of an ounce of food is released from the stomach to the small intestine at a time. It typically takes approximately three to four hours for contents to pass entirely through the stomach, although the time varies according to the types of food ingested (foods high in fat and/or fiber require more time to pass through the stomach). However, in patients with gastroparesis, the time required for food to pass through the stomach is much longer.

When food and liquid remain in the stomach for too long, it can cause complications including:

  • Weight loss and malnutrition. Patients with gastroparesis have less food enter the small intestine because of vomiting and they eat less because of symptoms.  This leads to weight loss and malnutrition.
  • Bezoars. Collections of solid masses of partially-digested or undigested materials, such as fiber or vegetable matter (phytobezoars). Bezoars can cause complications if they block food from entering the small intestine (intestinal obstruction).
  • Diabetes complications. Disruptions in the body’s ability to absorb food may result in wide fluctuations of blood sugar levels. When food is released from the stomach and is absorbed in the small intestine, blood sugar levels rise. When blood sugar levels are erratic, they are more difficult for diabetes patients to control.

Gastroparesis can also cause overgrowth of bacteria in the stomach and impair the absorption of oral medications.

Risk factors and causes of gastroparesis

Gastroparesis is typically caused by damage to the vagus nerve. This nerve, which originates in the brainstem and is involved in sensory and motor functions, also controls the muscular contractions of the stomach. Damage to the stomach muscles can also cause gastroparesis, although this is less common.

There are a number of risk factors that can result in damage to the vagus nerve or stomach muscles. The most common is diabetes. Elevated blood sugar (glucose) levels experienced by patients with diabetes can result in damage to the vagus nerve.

Another common risk factor is surgery to the esophagus, stomach or duodenum (the first part of the small intestine connected to the stomach). Gastroparesis can develop immediately after any of these surgeries or years later. However, not every patient who experiences damage to the vagus nerve during surgery will develop gastroparesis.

Other common risk factors of gastroparesis include:

  • Medications. Certain common medications can delay the emptying of stomach contents. These drugs include narcotic pain medications, tricyclic antidepressants (medications to treat depression), lithium (medication to treat mood disorders) and progesterone (a female hormone that is used in oral contraceptives [birth control pills] and hormone replacement therapy). When patients stop taking the medication, however, symptoms usually improve.

  • Cancer treatments. Patients who receive chemotherapy or radiation therapy to the chest sometimes develop gastroparesis.

  • Other disorders. There are a wide range of disorders that have been linked to gastroparesis, including eating disorders (e.g., anorexia nervosa, bulimia nervosa), smooth muscle disorders (e.g., scleroderma), nervous system diseases (e.g., Parkinson’s disease), cyclic vomiting syndrome, cirrhosis, kidney failure and metabolic disorders (e.g., high levels of thyroid hormones). Viral infections can also lead to gastroparesis in some people.

In some patients, the cause of gastroparesis is unknown (idiopathic).

Signs and symptoms of gastroparesis

The most common signs and symptoms of gastroparesis include:

  • Nausea
  • Vomiting
  • Feeling full early into a meal (early satiety)
  • Abdominal bloating or discomfort
  • Heartburn or gastroesophageal reflux
  • Fluctuations in blood sugar levels
  • Lack of appetite
  • Constipation or diarrhea

Symptoms may be mild or severe, depending on the patient. Patients may experience symptoms only after eating solid foods, after eating solid foods and drinking liquids or, in rare cases, only after ingesting liquids. Some patients vomit several hours after eating when the stomach is full. Patients who have difficulty absorbing nutrients due to the condition may experience weight loss and malnutrition.

Diagnosis methods for gastroparesis

Gastroparesis is usually diagnosed by a physician during a physical examination that includes the patient’s medical history.

There a number of tests that a physician may perform to diagnose gastroparesis. They include:

  • Blood tests. These check levels of substances in the blood, including glucose (blood sugar). Erratic glucose blood levels is one possible sign of gastroparesis. Blood tests can indicate malnutrition in extreme cases of gastroparesis.

  • Gastric emptying study. Test that measures the rate at which contents exit the stomach. The test is widely available and often considered the best way to determine whether a patient has gastroparesis. During the test, a patient eats solid food (usually eggs or oatmeal) that contains a tiny amount of radioactive material. After eating, the patient lies underneath a machine that takes pictures of the food as it passes through the stomach.

  • Upper GI barium test. Allows physicians to analyze pictures of the patient’s stomach. After fasting for at least 12 hours, the patient ingests barium (a white liquid that shows up on x-rays) before x-rays are taken. The stomach is normally empty after a 12-hour fast. Therefore, if food remains in the stomach, it may indicate gastroparesis.

  • Barium beefsteak meal. Test that allows physicians to observe the stomach during a meal. Patients ingest food that contains barium and the stomach is observed through x-rays, which allows the physician to determine how well the stomach is functioning. This test may detect problems that do not appear during the upper GI barium test.

  • Antroduodenal motility study. The patient is sedated or has the throat numbed. A tube is passed down the throat and through the stomach into the upper part of the small intestine. Sensors in the tube measure the contractions of the digestive tract at rest and after a meal and reveal whether emptying of the stomach is delayed. The test evaluates the contraction ability of the stomach and duodenum muscles.

  • Gastroduodenal manometry. Test that measures the strength, frequency and coordination of muscle contractions in the stomach and small intestine while eating. It is conducted by inserting a tube (manometry catheter) through the esophagus into the stomach to the small intestine. Muscle contractions are recorded before and after the patient eats. This test is not widely available and may not be necessary for diagnosing gastroparesis.

To help rule out conditions other than gastroparesis that may be producing symptoms, a physician may perform the following tests:

  • Upper endoscopy. Test that allows the physician to inspect the stomach for abnormalities. A thin tube with a tiny camera (endoscope) is inserted into the mouth and passed through the esophagus into the small intestine. This test, which is usually performed with a sedative, can detect conditions that may be causing gastric emptying problems, such as cancer or hernias.

  • Small intestinal x-ray. Test in which pictures of the small intestine are taken. This can detect blockages which may be causing gastric emptying problems.

  • Ultrasound. Test that uses sound waves to produce images of the shape and outline of various tissues and organs in the body. This test can help a physician detect other problems that may be causing symptoms, such as gallbladder disease or pancreatitis.

Treatment and prevention of gastroparesis

There is no cure for gastroparesis. However, most patients lead normal lives with treatment.

Treatment usually involves management of other conditions and diseases, such as diabetes, that are underlying causes of gastroparesis. Diabetes can be controlled with dietary modifications, insulin (a hormone that regulates blood sugar [glucose])  and other medications, exercise and careful monitoring of glucose levels.

Treatment for gastroparesis typically involves making changes in diet and eating habits which may include:

  • Eating smaller meals more frequently. Eating six to eight smaller meals during the day instead of two to three large ones is often recommended because larger meals take longer to digest.
  • Avoiding foods with high levels of fat and/or fiber. The stomach requires more time to break down foods that are high in fiber, such as raw fruits and vegetables, whole grains and legumes. This is also true of fatty foods, such as fried foods.
  • Eating pureed or liquid foods. Some patients respond well to eating liquid foods, such as soup or pureed foods. These foods contain necessary nutrients but are easier to digest than solid foods.
  • Taking nutritional supplements. Patients sometimes take liquid supplements that contain vitamins and minerals because gastroparesis can result in insufficient absorption of nutrients.
  • Drinking water. Patients who experience frequent vomiting due to gastroparesis may become dehydrated. Drinking water can help avoid this. Water may be easier to ingest in patients experiencing nausea by taking small sips or sucking on ice chips.

Some patients with severe gastroparesis that does not respond to changes in diet and eating habits may require a feeding tube (jejunostomy) and enteral nutrition. During the procedure, a thin tube is inserted through the skin directly into the small intestine. Nutrients and medications are placed directly into the small intestine. By avoiding the stomach, problems with gastroparesis are avoided and nutrients are absorbed quickly into the bloodstream.

Some patients are treated with parenteral nutrition as an alternative to jejunostomy. This involves inserting a thin tube (catheter) through the skin and into a chest vein. A feeding bag containing liquid nutrients and medications is connected to the catheter. After entering the body, nutrients and medications are absorbed into the bloodstream.

Patients with gastroparesis may be treated with medications. The use of medications is limited, however, because of side effects and questionable effectiveness. Medications may be administered in liquid or injection form rather than pill form because pills are sometimes hard for patients to digest. Medications include:

  • Antiemetics. Used in the prevention or treatment of nausea and vomiting.
  • Prokinetics. Act on the muscles in the gastrointestinal tract to help move food through the digestive system.

Severe cases of gastroparesis that do not respond to dietary modifications, eating habit changes or medication may be treated with surgery (gastrojejunostomy). During surgery, the lower part of the stomach is stapled or bypassed. The remaining portion of the stomach is reconnected to a part of the small intestine (the jejunotomy). Because there are serious side effects associated with this procedure, it is usually only performed in patients with intestinal obstruction, a lack of response to other treatment options and those who are experiencing serious complications, such as malnutrition.

Some patients may be candidates for surgical implantation of a new device called a gastric stimulator, which helps control nausea and vomiting associated with gastroparesis.

Other treatment options for gastroparesis are currently being studied, including:

  • Electrical gastric stimulation. A battery-operated device is surgically implanted on the outer edge of the stomach. The device emits a mild electrical current that stimulates muscle contractions. Use of the device has been shown to increase the rate at which stomach contents are emptied and decrease nausea and vomiting.
  • Botulinum toxin (Botox). Research has shown that, in some people, botulinum toxin relaxes the pyloric sphincter (muscle between the stomach and small intestine). Relaxing the muscle allows more food to pass from the stomach to the small intestine. The effects are usually temporary.

In patients with diabetes, gastroparesis may be prevented by controlling blood sugar levels through proper diet and use of medications.

Questions for your doctor about gastroparesis

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to gastroparesis:

  1. I have diabetes. How likely is it that I will develop gastroparesis?
  2. I have lost weight recently even though I have not been trying. Could my weight loss be caused by gastroparesis?
  3. What is causing my gastroparesis?
  4. Are the symptoms I’m experiencing typical of gastroparesis?
  5. How will I know if I develop a bezoar?
  6. Will my gastroparesis end after I stop taking the medication that is causing it?
  7. Which tests will you perform to diagnose my suspected gastroparesis?
  8. What changes should I make to my diet and eating habits?
  9. What medication should I take (if any) to treat my gastroparesis?
  10. Could my gastroparesis have been prevented?
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