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Gastroparesis

Gastroparesis or delayed gastric emptying is when the stomach has trouble clearing out its contents, possibly due to issues with the stomach muscles, nerves, or brain and spinal cord nerves.

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Overview

Overview

  • Gastroparesis is when the stomach has trouble clearing out its contents. It is also known as delayed gastric emptying.
  • Food is moved within the stomach and out to the intestines through the action of muscles in the stomach wall. These muscles are under the control of the stomach’s own nerves and special cells called ICC (interstitial cells of Cajal) as well as by nerves coming from the brain and spinal cord (the vagus and the sympathetic nerves).
  • In a person with gastroparesis, the stomach does not work the right way, so food moves slowly into the small intestine or stops moving in the stomach. This may be due to problems in the muscle itself, in the nerves or ICC.
  • Gastroparesis is not a mechanical block in the stomach.
  • Gastroparesis is generally found more in women than in men, although the reason for this is unknown.
Symptoms and Causes

Symptoms and Causes

Symptoms are different for each person and can change in intensity and frequency over time. Common symptoms
  • Nausea.
  • Feeling full, even when eating only a small amount of food.
  • Throwing up (often throwing up whole pieces of food that have not been broken down in digestion).
    • Some patients can even identify food that they have eaten several hours (4 or more) before.
Other symptoms
  • GERD, also known as acid reflux. This can cause a burning feeling in the chest or throat known as heartburn.
  • Pain in the upper part of the belly (abdomen).
  • Losing weight without trying.
  • Bloating (swelling, usually above the belly button).
  • Not feeling hungry.
  • Weight loss and nutritional deficiencies in severe cases.
Certain factors may make symptoms worse
  • Eating greasy (high fat) foods.
  • Eating large amounts of food with fiber, such as raw fruits and vegetables.

Causes

  • Gastroparesis can happen in anyone. In most cases, the underlying cause of gastroparesis is not known and the disorder is called idiopathic gastroparesis. It is common in people with diabetes and roughly up to a third or slightly more of people with type 1 or type 2 diabetes may develop gastroparesis. When diabetes is the main cause of gastroparesis, it is called diabetic gastroparesis. People with diabetes have high levels of blood sugar, which can cause injury to the stomach muscle, nerves or ICC.
  • Other causes:
    • Problems from surgery done on the gut, which could result in vagal damage.
    • Nervous system diseases, such as Parkinson’s disease or multiple sclerosis (MS).
    • Medicine that blocks certain nerve signals to the stomach, particularly narcotics (opioids such as morphine, oxycodone, etc.).
    • Rheumatological disorders, such as scleroderma.
Testing

Testing

Common Tests
  • Physical exam.
  • Medical history.
  • Blood tests.
Further Tests To confirm the issue is gastroparesis and rule out the chance that it is a block or structural problem, your doctor may also do:
  • An upper GI endoscopy. During the endoscopy, your gastroenterologist will use a long, thin (about the width of your little finger), flexible tube with a tiny camera on the end to look inside, going through your mouth. You will be given medicine to block pain and make you feel relaxed and sleepy, so you won’t feel much during the test.
  • An upper GI series. With this test, you fast for eight hours and then swallow a special drink that makes it easier for food to show up on an X-ray.
  • An ultrasound, CT scan or MRI. These are tools to image the abdomen and see if other disorders such as gallbladder disease or pancreatitis could be the cause of the symptoms, instead of gastroparesis.
  • Gastric emptying scintigraphy. This is the best method for finding out how long a meal takes to empty from your stomach. You are given a test meal that has a small amount of radioactive material. It is then tracked by a radiologist using a special scanne, generally over 4 hours.
  • Capsule endoscopy. This uses a SmartPill, which is a small electronic device, shaped like a capsule, that you swallow. It records information as it moves through the digestive tract. It provides a different measure of gastric emptying that is not related to meals.
  • A gastric emptying breath test. In this test you are also given a meal that is made of a special kind of material that contains a heavy form of the element, Carbon. When this meal enters the small intestine, it is broken down and releases this carbon in the form of carbon dioxide that comes out in your breath and this can be measure by special machines. The rate of generation of this carbon dioxide is dependent on how fast the meal empties from your stomach.
Treatment

Treatment

In most cases, gastroparesis is a chronic (life-long) health issue that cannot be cured. Symptoms of gastroparesis can come and go. However, there are many treatment options, based on how bad your symptoms are, to help you care for gastroparesis. Talk to your doctor, especially if you have diabetes, about what treatments make sense for you. Controlling diabetes, if you have it, is one of the most important things you can do as a patient to improve your stomach function and symptoms. Diet and eating habits
  • Stay away from or limit high-fat foods and foods that have lots of fiber, such as oranges and broccoli. These can be hard to digest.
  • Chew food fully.
  • Consider eating six small meals a day instead of three large ones. Eating less food may make it easier for the stomach to empty, because it is not as full.
  • Seeing a nutritionist is an important part of the treatment and he or she can prescribe different kinds of diet depending on the severity of your symptoms. If symptoms are severe, a doctor may prescribe a liquid or puréed diet, because liquids empty faster from the stomach.
Medications
  • Metoclopramide is the only medication that is approved by the FDA for treating gastroparesis right now. It helps your stomach muscles move to help with gastric emptying. In addition, it works on the brain to suppress nausea. However, there are some risks to this medication, the most serious of which involve temporary or permanent problems with muscle twitching or spasms.
  • Erythromycin is an antibiotic that increases the movement of your muscles to help food move through your stomach. It may help some patients but the effects may wear off with time. Erythromycin can cause stomach pain and also interact with other medications that may effect your heart rhythm.
  • There are also other medications that may help gastroparesis symptoms, such as antiemetics (e.g. ondansetron or promethazine), which help control nausea.
  • Other drugs such as mirtazepine (an antidepressant) are also useful anti-nauseant drugs and can stimulate the appetite as well.
Alternative medicine options
  • Ginger tea or other preparations may help relieve nausea.
  • Some people also respond to acupuncture although there is as yet not enough evidence to be confident that it works.
Other treatment options
  • For patients with severe nausea and vomiting that do not get better with changes to your diet or medications, a doctor may do surgery to put a gastric neurostimulator in your stomach, which is a battery-operated device that sends electrical impulses to the stomach muscles. There is no clear evidence for the effectiveness of this therapy and the FDA has only approved it on “compassionate grounds”.
  • When gastroparesis is very severe and the symptoms are not getting better with other treatment options, there are a few more options, only to be done if needed.
    • A jejunostomy may be needed. Using surgery, a doctor puts a feeding tube into a part of the small intestine called the jejunum. This can be done surgically or endoscopically via the stomach, when it is called a PEG/J.
    • Total parenteral nutrition (TPN), an IV liquid food mixture that is given through a tube in the chest, may also help. This may be used as a temporary treatment. The tube is put into the chest during a surgery.
  • There is no evidence for supporting the use of botulinum toxin injections for the treatment of gastroparesis.
  • Cutting the muscle at the pylorus (the junction between the stomach and intestine) is being performed at some centers both surgically and endoscopically but at this point is considered experimental with no strong evidence to support it.
Things to be aware of If gastroparesis gets out of hand, it can cause:
  • Severe dehydration or loss of water from the body (with vomiting that doesn’t stop).
  • Esophagitis — pain and swelling in the esophagus (the tube that links the mouth and the stomach).
  • Bezoars (a small mass in your stomach) that can cause nausea, vomiting, a block, or stop your body from using some medications the right way.
  • Trouble controlling blood sugar levels in people with diabetes.
  • Malnutrition, which can stop the body from getting the vitamins, minerals and nutrients it needs.
  • Worsening quality of life – missing work and social events due to symptoms.
Diabetic Gastroparesis

Diabetic Gastroparesis

Muscles, including those of your stomach, need healthy nerves to trigger and control movement. But, over time, high blood glucose (a type of sugar that your body uses for fuel) from diabetes can harm the nerves. The signals needed for the body to work the right way don’t get sent out. Diabetes can also injure the blood vessels. As a result, the nerves don’t get the oxygen and nutrients they need. Generally, when food and fluid move into the stomach, muscles in the stomach wall mix the food and liquid and churn it into smaller pieces. Glands in the stomach add other fluids, like acids and enzymes, to help break down the food and fluid. Together, they make a substance called chyme. When diabetes causes injury to the nerves, the stomach muscles don’t make the strong wave-like movements (peristalsis) that carry chyme to the duodenum (the first part of your small intestine). The muscle contractions are slower, less powerful, or less frequent. Some of the chyme stays in the stomach and the stomach doesn’t empty fully. Stomach emptying also slows when you eat foods that are high in fat and fiber.

Causes of gastroparesis

In most cases, the cause of gastroparesis is not known. This is called idiopathic gastroparesis. In up to a third or slightly more cases, the cause is diabetes. High levels of blood glucose from diabetes can injure the stomach muscle, the nerves, or ICC. In fact, diabetes is the most frequently identified disease linked to gastroparesis. Hyperglycemia (high blood glucose levels) affects the muscles of the stomach.
  • The muscles in the upper part of the stomach become more relaxed.
  • The muscles in the middle and lower parts of the stomach aren’t able to shorten as often or with the usual amount of force.
  • The signals from the nerves to the stomach muscles are altered so that the wave-like action occurs unevenly.
  • All these events slow the emptying of your stomach.
Delayed gastric emptying can also affect blood glucose levels and control of diabetes. How fast or slow the stomach empties can change how the body absorbs the carbohydrates and fats (the main nutrients that provide the body with energy) that are eaten.

Long-term concerns

Diabetic gastroparesis is a chronic condition. There is no cure, but the condition can be managed. With medicines, changes to the diet, and other forms of treatment, you can learn to take charge and control it. That way, you’ll be able to do more things that matter to you. You can feel and live better, with fewer symptoms. Remember, you’re not alone. Your health care team is there to support you. Work closely with them on a treatment plan that meets your needs. Talk with your health care provider about goals and challenges. Speak up if you have concerns. Also, be sure to get answers to any questions you have. Know that even small changes can result in big improvements in your health over time.

Possible complications

Sometimes, even with treatment, problems can arise that can upset how well you are managing your condition. In addition to those that might happen with diabetes, diabetic gastroparesis can cause:
  • Severe dehydration or loss of water and electrolytes (minerals found in the body) from vomiting that doesn’t stop.
  • Esophagitis (pain and swelling in the esophagus—the tube that links the mouth and the stomach).
  • Bezoar (a small mass of food, fiber or other substances in the stomach) that can cause nausea, vomiting, a block, or stop the body from using some medicines the right way.
    • Sometimes, food in the stomach is broken down only a bit or not at all. This food then forms a tight mass that can block the movement of chyme out of the stomach. The mass is called a bezoar. Fiber, peels, and seeds from fruits and vegetables are likely causes.
    • Bezoars may cause no symptoms. But if symptoms do occur, they may include feeling full after a meal, nausea, vomiting, not feeling hungry, and weight loss. Treatment includes dissolving the mass or removing it.
  • Malnutrition, which happens when the body doesn’t get the vitamins, minerals, and nutrients it needs. This can lead to weight loss and raise the risk of infection.
  • Worsening quality of life from not being able to do what you want to do because of your symptoms.

Diagnosing diabetic gastroparesis

The signs and symptoms of delayed gastric emptying are the same as many other conditions. To make sure gastroparesis is the cause, your health care provider will get a medical and family history and perform a physical exam. They will also likely want some blood tests done. More testing may be needed to rule out other conditions as the cause. Medical and family history. Taking a medical and family history can help your health care provider get a clearer picture of what is going on. Be sure to tell your health care provider about all your symptoms. Include when they happen, how severe they are, and what helps to make them better or worse. Your health care provider will also ask about any medical conditions and medicines. Tell them about your diabetes and what you do to manage your blood glucose levels. Also, let them know if you have had problems with keeping your diabetes under control. Physical exam. During a physical exam, the health care provider most often looks at the belly for any swelling; listens to the belly for sounds using a stethoscope; and examines the belly with the hand to check for tenderness and pain. Blood tests. A blood test involves getting a sample of blood at your health care provider’s office or a lab. A lab technologist will look at the sample. Blood tests may be done to check:
  • Blood counts for changes that might suggest anemia (a condition where there aren’t enough healthy red blood cells), dehydration, or infection.
  • Levels of electrolytes, protein, and other substances.
  • Blood glucose level.
  • Hemoglobin A1C (a measure of your average blood glucose level over a few months).
Imaging tests. Ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI) make images of the belly. They are used to see if other disorders could be the cause of the symptoms. Sometimes, imaging tests can identify a block in the lower end of the stomach that is preventing the stomach from emptying.

Procedures for diagnosing diabetic gastroparesis

A health care provider may want some procedures done to confirm diabetic gastroparesis. These help to rule out the chance that the symptoms are due to a block or structural problem. Talk with your health care provider about how to get ready for the procedures, including taking medicines and not eating or drinking before the procedure. Upper gastrointestinal (GI) endoscopy. During an upper GI endoscopy, a long, thin, flexible tube is passed through the mouth and into the stomach. The tube is about the width of the little finger. It has a light and camera on the end. The camera sends pictures of what it sees to a monitor. You will be given medicine to block pain and make your feel relaxed and sleepy so you won’t feel much during the procedure. Upper GI series. Your health care provider may suggest this procedure instead of an upper GI endoscopy. An upper GI series is an X-ray that takes pictures of the esophagus, stomach, duodenum, and small intestine. Before the procedure, you will drink a chalky liquid called barium. The barium makes it easier for food to show up on the X-ray. X-ray pictures are taken as the barium travels from the mouth to the stomach. These pictures can be used to make a diagnosis and plan more specific treatments. Gastric emptying scintigraphy. This is the best method for finding out how long it takes for a meal to empty from the stomach. You are given a test meal (usually eggs) that has a small amount of radioactive material. The amount is not harmful. After eating, you will lie under or stand in front of a special machine called a scanner that has a camera. Pictures will be taken with the camera in front or behind you. The scanner will track how quickly the food moves through the stomach. The tracking is usually done over 4 hours. Each scan takes about 2 minutes and is done every hour after the meal. Capsule endoscopy. This procedure uses a small electronic device that looks like a capsule. It is about the size of a large pill. You will swallow the capsule at your health care provider’s office. As the capsule travels through the digestive system, it sends images to a device worn around your waist that saves them. The capsule leaves through a bowel movement. This procedure measures stomach emptying in a way that does not involve a meal. But, you will be given a standard “bar” to eat during the procedure. You will be asked not to eat anything else until 5 hours have passed from the time you took the capsule. Gastric emptying breath test. With this procedure, you are given a meal with a special kind of material that contains a heavy (but not radioactive) form of the element carbon. When the meal enters your small intestine, it breaks down and releases this carbon in the form of carbon dioxide that comes out in your breath. A special machine measures this carbon dioxide. The rate at which you produce this carbon dioxide depends on how fast the meal empties from your stomach.

Treating diabetic gastroparesis

Being diagnosed with a chronic condition, such as diabetes, can be life-changing. And finding out that you have another chronic illness due to diabetes can be even more upsetting. It’s okay to feel sad, guilty, or even afraid. These feelings are natural and understandable. Give yourself time to adjust to the news and to the changes that the diagnosis brings. Know your feelings will likely improve with time and as you learn more about caring for yourself. Talk with your health care team about how you’re feeling. They can help you feel less overwhelmed and more ready to plan for a healthy future. Learning how to manage your chronic conditions takes work. And it doesn’t happen overnight. Take it one step at a time. With practice, managing your diabetic gastroparesis can become part of your life. You’ll gain confidence as you take charge of your life and your health.

Blood glucose control

Controlling your diabetes is one of the most important things you can do to improve your stomach function and symptoms. When your diabetes is under control, your risk for other problems throughout your whole body lessens, too. When blood glucose levels are high, the stomach has trouble moving food out of it. High blood glucose levels also harm the nerves that make the stomach muscles move. Slower emptying means food is absorbed more slowly and unevenly. This can lead to wide-ranging changes in your blood glucose levels. Use these tips to help you make the most of your diabetes management plan.
  • Understand the medicines you are taking. Take them exactly as directed. When you have diabetic gastroparesis, your health care provider may change your medicine or dose or have you take it at a different time.
  • Know what your target blood glucose level is. Understand what to do if your numbers are outside your target range.
  • Check your blood glucose levels as often as your health care provider recommends. Keep a record of your readings. Call your health care provider if your readings are staying above your target range.
  • Watch for signs and symptoms of high blood glucose, such as being thirsty, urinating more, or feeling more tired. Know what to do if your blood glucose is high
  • Follow your meal plan. Be aware of what foods cause your blood glucose to go up. If your health care provider advises you to increase the amount of vegetables and fruits in your diet, remember that those high in fiber may empty from the stomach more slowly. Cooking them and then passing them through a blender can help move these foods along better once they are eaten.
  • Be as physically active as you can. Being active can help keep your blood glucose under control. And it may help to speed up gastric emptying. Pick activities that you enjoy. You’ll be more likely to make the activity a habit.
  • Have a sick day plan and follow it. Remember, blood glucose can rise quickly when you are sick.

Medicines

Several medicines may be used to treat delayed gastric emptying. These are called prokinetic medicines. These medicines help move substances along the digestive system by increasing the number and strength of muscle contractions. The result is that the stomach empties more quickly. Your health care provider will work with you to find out what medicines might be best. Metoclopramide At this time, metoclopramide is the only medicine approved by the U.S. Food and Drug Administration (FDA) to treat gastroparesis. It helps the stomach muscles move so the stomach can empty. It also works on the brain to control nausea. However, there are some risks with this medicine. The most serious risk involves problems with muscle twitching, spasms, or involuntary movements. These movements may affect the face, tongue, or limbs, such as your hands. They may be temporary or permanent. But for most patients, these side effects disappear when the medicine is stopped. Erythromycin Erythromycin is an antibiotic that increases the movement of your muscles to help move food through the stomach. It may help some patients but the effects can wear off with time, sometimes in a few days or weeks. Erythromycin can cause stomach pain and also interact with other medicines. Diabetes medicines and delayed gastric emptying Some medicines used to treat diabetes have been shown to slow gastric emptying. These include medicines such as pramlintide, liraglutide, and exenatide. If you are taking one of these medicines and have diabetic gastroparesis, your health care provider may switch you to another medicine. Other medicines Other medicines may be used to treat the symptoms of diabetic gastroparesis. Antiemetics, such as ondansetron or promethazine, may be used to control nausea. Mirtazapine, a medicine used for depression, may also help control nausea. This medicine can also help improve your desire for food.

Meal planning

Meal planning in diabetes is important to keep your blood glucose levels under control. It is even more important when you have diabetic gastroparesis. No one meal plan works for everyone. The symptoms of diabetic gastroparesis can upset what and how much you eat. This can lead to problems with not getting the right nutrients to stay healthy. And you may have trouble keeping your blood glucose levels under control. Work with your health care provider and dietitian to create a diet plan that meets your needs. Getting the right nutrients Nutrients are those things that are important for you to stay healthy. Getting the right nutrients means you’re eating a good balance of proteins, carbohydrates, fats, vitamins, minerals, and water. And eating the right balance of carbohydrates is key to keeping your blood glucose in your target range. Eating for your health It is important to drink and eat plenty of food in a form that you can tolerate. This helps make sure you protect your other body functions, such as your kidneys. It also helps you maintain a healthy body weight. Dietary changes are very important. Your health care provider may suggest using a blender and cooking foods thoroughly, especially vegetables, to make it easier for them to empty from your stomach. Making the best food choices When you have diabetes, eating food from all the food groups gives your body the nutrients it needs and keeps your blood glucose levels in their target range. With diabetic gastroparesis, you’ll likely feel better if you also limit or avoid foods that are high in fat and fiber. But what to choose? The list below gives you some examples. Tips for eating Here are some tips for eating when you have diabetic gastroparesis.
  • Fiber and fat can slow the emptying of your stomach. Fiber can also clump together and cause a blockage. So, it’s best to stay away from or limit foods that are high in fat and fiber. When eating fruits and vegetables, remember to cook them thoroughly and pass them through a blender.
  • Solid food in the stomach is harder to break down. Be sure to chew your food well before swallowing it. Try braising, poaching, simmering, and stewing for cooking. These methods make food tender and easier to chew. Blenderizing foods to be like a thick soup can also help.
  • Smaller meals can help lessen bloating. Plus, eating less food may make it easier for the stomach to empty because it is not as full. Try eating 5 to 6 small meals a day instead of 3 large ones.
  • Sitting up when eating also helps to lessen the pressure in the stomach and makes it easier for the stomach to empty. Avoid lying down after eating.
  • Alcohol and smoking can slow gastric emptying. Avoid them.
  • Carbonated drinks can give off carbon dioxide (gas) and make you feel bloated. Try to limit or avoid them.
  • Drinking large amounts of fluid at one time at a meal can add to bloating. Taking small amounts or sips of fluid throughout your meal can help the stomach empty.

When you can’t eat

There may be times when you can’t eat or your symptoms are not getting better. Or your symptoms may keep coming back even with treatment. Your health care provider may advise you to have a feeding tube placed for a short time.
  • A jejunostomy tube is a small tube put in by your health care provider. The tube is put through the skin on your belly into a part of the small intestine called the jejunum (the area after the duodenum). A special liquid food that has nutrients is used with the tube. The nutrients skip the stomach and go directly to the small intestine, where they are absorbed. This may help to control blood glucose levels better.
  • Total parenteral nutrition (TPN) gives you nutrients through an intravenous (IV) line. A health care provider puts a thin tube into a blood vessel (a vein) in your chest during surgery. A sterile liquid food mixture is then given through the tube into the vein in your chest. This may be used as a temporary treatment.
Surgery Surgery or an endoscopic procedure to open the valve at the end of the stomach is not often done to treat diabetic gastroparesis. But, it may be an option if you have severe nausea and vomiting that do not get better even with medicines and changes to your diet. Talk with your health care provider to see if either of these is an option for you. Other treatments Alternative treatments may also be a choice. But there is little scientific evidence to support them. For example, some people may get relief from nausea with ginger tea, other teas or acupuncture. Research is also being done to look into other surgeries and medicines that may be helpful in controlling the symptoms. 10 questions to ask your health care provider The best way to help manage your diabetic gastroparesis is to learn as much as you can about it. Plan ahead to ask your health care provider the questions you need answered.
  1. How do you know I have diabetic gastroparesis?
  2. What are the signs and symptoms?
  3. How will my condition affect my diabetes?
  4. How will this condition affect my ability to work, travel, and maintain my everyday lifestyle?
  5. Do I need to make changes with my diet? If so, what changes do I need to make?
  6. Will I need to change how I manage my diabetes? If so, how?
  7. What are my treatment options?
  8. What are the benefits and risks of these options?
  9. What can I do to monitor my condition?
  10. When should I call my health care provider?
References

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