Weakness of gastric peristalsis, which results in delayed emptying of the bowels.
Alternative Names: Gastroparesis diabeticorum; Delayed gastric emptying.
The stomach is a hollow organ composed primarily of muscle that serves as a storage container for food. Food in the stomach is ground into tiny pieces by the constant churning that is generated by the contractions of the stomach's muscles. Once the food has been adequately ground, it slowly is emptied from the stomach into the intestine in a metered fashion. Only food ground into small particles can be emptied from the stomach in a normal fashion, and smaller particles are digested better in the intestine. Moreover, the metering process allows the emptied food to be well-mixed with the digestive juices of the intestine, pancreas, and liver (bile) and to be absorbed well from the intestine.
When the stomach's muscles are paralyzed, food is not thoroughly ground and does not empty into the intestine normally. Since the muscular mechanisms whereby ground, solid food and liquid food are emptied from the stomach are different, there may be delayed emptying of solid food (most common), solid and liquid food (less common), or liquid food alone (least common). Gastroparesis means paralysis of the muscles of the stomach. Gastroparesis results in delayed emptying of food from the stomach into the small intestine.
Gastroparesis, also called delayed gastric emptying, is a disorder in which the stomach takes too long to empty its contents. Normally, the stomach contracts to move food down into the small intestine for digestion. The vagus nerve controls the movement of food from the stomach through the digestive tract. Gastroparesis occurs when the vagus nerve is damaged and the muscles of the stomach and intestines do not work normally. Food then moves slowly or stops moving through the digestive tract.
Gastroparesis can make diabetes worse by making blood glucose control more difficult. 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.
If food lingers too long in the stomach, it can cause 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.
One of the best ways to help control the symptoms of gastroparesis is to modify your daily eating habits. For instance, instead of three meals a day, eat six small meals. In this way, there is less food in your stomach; you won't feel as full, and it will be easier for the food to leave your stomach. Another important factor is the consistency of food; liquids and low residue foods are encouraged (for example, applesauce should replace whole apples with intact skins). You should also avoid foods that are high in fat (which can slow down digestion) and fiber (which is difficult to digest).
Signs and symptoms of gastroparesis are
- Pain in the upper abdomen.
- Vomiting of undigested food—sometimesseveral hours after a meal.
- Early feeling of fullness after only afew bites of food.
- Weight loss due to poor absorption ofnutrients or low calorie intake.
- Abdominal bloating
- High and low blood glucose levels
- Lack of appetite
- Gastroesophageal reflux
- Spasms in the stomach area.
Eating solid foods, high-fiber foods such as raw fruits and vegetables, fatty foods, or drinks high in fat or carbonation may contribute to these symptoms. The symptoms of gastroparesis may be mild or severe, depending on the person. Symptoms can happen frequently in some people and less often in others. Many people with gastroparesis experience a wide range of symptoms, and sometimes the disorder is difficult for the physician to diagnose.
Causes and Risk factors:
Gastroparesis can be caused either by diseases of the stomach's muscles or the nerves that control the muscles, though often no specific cause is identified. The most common disease causing gastroparesis is diabetes mellitus which damages the nerves controlling the stomach muscles. Gastroparesis also can also result from damage to the vagus nerve, the nerve that controls the stomach's muscles, that occurs during surgery on the esophagus and stomach. Scleroderma is an example of a disease in which gastroparesis is due to damage to the stomach's muscles. Occasionally, gastroparesis is caused by nervous reflexes, for example, when the pancreas is inflamed (pancreatitis). In such cases, neither the nerves nor the muscles are diseased, but messages are sent through nerves from the pancreas to the stomach which prevents the muscles from working normally.
Other causes of gastroparesis include imbalances of minerals in the blood such as potassium, calcium or magnesium, medications (such as narcotic pain-relievers), and thyroid disease.
Gastroparesis can occur as an isolated problem or it can be associated with paralysis of other parts of the intestine, including the esophagus, small intestine, and colon.
The most common cause of gastroparesis isdiabetes. People with diabetes have high blood glucose, also called blood sugar,which in turn causes chemical changes innerves and damages the blood vessels thatcarry oxygen and nutrients to the nerves.Over time, high blood glucose can damagethe vagus nerve.
Some other causes of gastroparesis are:
Surgery on the stomach or vagus nerve.
- Viral infections.
- Anorexia nervosa or bulimia.
- Medications—anticholinergics andnarcotics—that slow contractions in the intestine.
- Gastroesophageal reflux disease.
- Smooth muscle disorders, such as amyloidosisand scleroderma.
- Nervous system diseases, includingabdominal migraine and Parkinson's disease.
- Metabolic disorders, including hyperthyroidism.
- Many people have what is called idiopathicgastroparesis, meaning the cause is unknown and cannot be found even aftermedical tests.
- Abdominal surgery.
- Taking medications that slow the rate of stomach emptying.
- Certain cancer medications.
- Medications that affect muscles or nerves.
To diagnose gastroparesis, your doctor will review your symptoms and medical history. He or she will also give you a physical examination and may order certain blood tests, including blood sugar levels. Other tests used to diagnose and evaluate gastroparesis may include:
Barium X-ray: You drink a liquid (barium), which covers your esophagus, stomach, and small intestine and shows up on X-ray. This test is also known as an upper GI (gastrointestinal) series or a barium swallow.
- Barium beefsteak meal: You eat a meal with barium in it, and the doctor observes your stomach on X-ray as it digests the meal. The rate of digestion will tell your doctor how quickly your stomach is emptying.
- Radioisotope gastric-emptying scan: You eat food that contains a radioisotope (a radioactive substance), then lie under a scanning machine; if the scan shows that more than half of the food is still in your stomach after two hours, you are diagnosed with gastroparesis.
- Gastric manometry: A thin tube that is passed through your mouth and into your stomach measures the stomach's electrical and muscular activity to determine the rate of digestion.
- Electrogastrography: measures electrical activity in the stomach using electrodes placed on the skin.
- Ultrasound: This is an imaging test that uses sound waves to create pictures of body organs. Your doctor may use ultrasound to eliminate other diseases.
- Upper endoscopy: This procedure involves passing a thin tube (endoscope) down your esophagus to examine the lining of your stomach.
Treatment of gastroparesis depends on the severity of the symptoms. In most cases, treatment does not cure gastroparesis—it is usually a chronic condition. Treatment helps you manage the condition so you can be as healthy and comfortable as possible.
- Several medications are used to treat gastroparesis. Your doctor may try different medications or combinations to find the most effective treatment. Discussing the risk of side effects of any medication with your doctor is important.
- Metoclopramide (Reglan): This drug stimulates stomach muscle contractions to help emptying. Metoclopramide also helps reduce nausea and vomiting. Metoclopramide is taken 20 to 30 minutes before meals and at bedtime. Side effects of this drug include fatigue, sleepiness, 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 include nausea, vomiting, and abdominal cramps.
- Domperidone: This drug works like metoclopramide to improve stomach emptying and decrease nausea and vomiting. The FDA is reviewing domperidone, which has been used elsewhere in the world to treat gastroparesis.
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 in the stomach, the doctor may use an endoscope to inject medication into it to dissolve it.
The primary treatment goals for gastroparesis related to diabetes are to improve stomach emptying and regain control of blood glucose levels. Treatment includes dietary changes, insulin, oral medications, and, in severe cases, a feeding tube and parenteral nutrition.
Dietary Changes: Changing your eating habits can help control gastroparesis. Your doctor or dietitian may prescribe 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. In more severe cases, a liquid or pureed diet may be prescribed. The doctor may 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 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.
The doctor will suggest dietary changes such as six smaller meals to help restore your blood glucose to more normal levels before testing you for gastroparesis. In some cases, the doctor or dietitian may suggest you try eating several liquid or pureed meals a day until your blood glucose levels are stable and the symptoms improve. Liquid meals provide all the nutrients found in solid foods, but can pass through the stomach more easily and quickly.
If a liquid or pureed diet does not work, you may need surgery to insert a feeding tube. The tube, called a jejunostomy, is inserted through the skin on your abdomen into the small intestine. The feeding tube bypasses the stomach and places nutrients and medication directly into the small intestine. These products are then digested and delivered to your bloodstream quickly. You will receive special liquid food to use with the tube. The jejunostomy is used only when gastroparesis is severe or the tube is necessary to stabilize blood glucose levels in people with diabetes.
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 period with gastroparesis. Parenteral nutrition is used only when gastroparesis is severe and is not helped by other methods.
Gastric Electrical Stimulation: A gastric neurostimulator is a surgically implanted battery-operated device that releases mild electrical pulses to help control nausea and vomiting associated with gastroparesis. This option is available to people whose nausea and vomiting do not improve with medications. Further studies will help determine who will benefit most from this procedure, which is available in a few centers across the United States.
Botulinum Toxin: The newest experimental treatment for gastroparesis is injection of botulinum toxin into the pylorus. The pylorus is the narrow channel through which food passes from the stomach to the duodenum. The pylorus, like the stomach, is a muscular organ. The pylorus is closed most of the time due to continuous contraction of the pyloric muscle. Intermittently it opens and allows secretions from the stomach to enter the small intestine. After meals, the pylorus is very important for metering the emptying of the stomach. In gastroparesis, although the muscles of the stomach are weak all of the time, the muscle of the pylorus remains strong and contracted and the pylorus relatively closed. It was hypothesized that if the strength of the pyloric muscle was reduced, food might empty from the stomach more readily. Although a surgical procedure, termed pyloroplasty, to enlarge the pylorus has been used in the past to treat problems with emptying of the stomach, it is major surgery and has had mixed results with respect to its efficacy. More recently, relaxation of the pyloric muscles has been produced by injecting botulinum toxin (Botox) into the pylorus. Although results have been good, the procedure has not been studied enough to recommend its use unless it is part of a research protocol.
Medicine and medications:
Some patients may benefit from medications, including:
Reglan: You take this drug before you eat, and it causes your stomach muscles to contract to help move food out of your stomach. Reglan also decreases the incidence of vomiting and nausea. Side effects include diarrhea and, rarely, a serious neurological disorder.
DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.
- Erythromycin: This is an antibiotic that also causes stomach contractions and helps move food out. Side effects include diarrhea and development of resistant bacteria from prolonged exposure to the antibiotic.
- Antiemetics: These are drugs that help control nausea.
- People who have diabetes should try to control their blood sugar levels to minimize the problems of gastroparesis.