Gastroparesis

Question 1

The motility of the stomach is initiated in the pacemaker region of the stomach which is in the _______

Answer 1

fundus. Waves then propagate toward the pylorus

Question 2

How frequently does the stomach contract?

Answer 2

about once every 20 seconds or 3x/min

Question 3

Note about movement of food through the stomach

Answer 3

peristaltic waves push food from the fundal region into the plyoric region where at most times the pyloric sphincter is constricted to almost produce retrograde movement and continue to break down food until it is small enough to pass through the pylorus into the duodenum

Question 4

What is gastric accommodation?

Answer 4

ingestion of food is associated with distension of the stomach fundus/body from abotu 200ml to about 500ml

Question 5

Describe gastric emptying

Answer 5

At 60 minutes most of the food is still in the fundus (~80%), 30-40% at 2 hrs and, and by 4 hrs the vast (95%) majority as passed out of the stomach

Below is a normal solid meal

Question 6

In contrast, liquids pass much more quickly through the stomach with 50% being passed in about an hour

Question 7

What is gastroparesis?

Answer 7

delayed gastric emptying NOT caused be mechanical obstruction

Question 8

What are the cardinal symptoms of gastroparesis?

Answer 8

Nausea (93%)

, vomiting,

early satiety (60-86%),

bloating

abdominal pain (46-90%)- probably not the primary symptom

weight loss as the condition becomes more severe

Question 9

Question 10

What are some main causes of gastroparesis?

Answer 10

• idiopathic (most common)
• Infiltrative processes (scleroderma, amyloidosis)

Dysautonomia (diabetic or amyloid neuropathy)

-CNS disorders (stress, Parkinsonism, MS, etc.)

Question 11

Question 12

What are some medications that can delay gastric emptying?

Answer 12

• opiates/narcotics
• clonidine
• CCBs
• tricyclic antidepressants

Question 13

Up to 50% of all cases of gastroparesis are due to _______

Answer 13

idiopathic

Question 14

How common is gastroparesis in diabetics?

Answer 14

Up to 30-60% of type I diabetics will develop GP after longstanding disease while

up to 30% of type II diabetics will

Question 15

What part of diabetes caused gastroparesis?

Answer 15

The entire pathogenesis is not completely understood but it is partially due to neuropathy and hyperglycemia itslef can delay gastric emptying

Question 16

Question 17

What surgeries most commonly lead to gastroparesis?

Answer 17

billroth II

fundoplication (an anti-reflux surgery)

Question 18

How can a mechanical obstruction be eliminated from the Ddx in pts with suspected gastroparesis?

Answer 18

usually via an upper endoscopy

or CT or barium studies

Question 19

What is this?

Answer 19

gastric outlet obstruction (stenosed pylorus)- not technically gastroparesis. This is usually due to an ulcer and can actually be dilated at the time of the procedure or may be treated with a PPI

Question 20

What is this?

Answer 20

barium study showing gastric outlet obstruction. Usually followed by endoscopy

Question 21

Notice how much the stomach is dilated

Question 22

What is the test of choice to make the diagnosis of gastroparesis?

Answer 22

a gastric emptying study

Question 23

Question 24

Typically, the 4hr is more important

Question 25

What things need to be on the differential for gastroparesis?

Answer 25

• psychiatric disease
• rumination syndrome
• functional dyspepsia
• cyclic vomiting syndrome

Question 26

What is rumination disease?

Answer 26

Rumination syndrome, or Merycism, is an under-diagnosed chronic motility disorder characterized by effortless regurgitation of most meals following consumption, due to the involuntary contraction of the muscles around the abdomen. There is no retching, nausea, heartburn, odour, or abdominal pain associated with the regurgitation, as there is with typical vomiting. The disorder has been historically documented as affecting only infants, young children, and people with cognitive disabilities (the prevalence is as high as 10% in institutionalized patients with various mental disabilities). Today it is being diagnosed in increasing numbers of otherwise healthy adolescents and adults, though there is a lack of awareness of the condition by doctors, patients and the general public.

Question 27

Question 28

Question 29

Dietary management of gastroparesis

Answer 29

High fat diets will delay gastric emptying

Question 30

Pharm management of GP

Answer 30

Question 31

What is Metoclopramide?

Answer 31

A dopamine receptor 2 antagonist that enhances gastric antral contractions

5-20 mg QID. Approved for use up to 12 weeks

Question 32

What limits Metoclopramide use?

Answer 32

Side effects are seen in up to 30% of users including:

drowsiness, fatigue, agitation and hyperprolactinemia (galactorrhea, amenorrhea, etc.). These are reversible

tardive dyskinesia in 1-10% of pts. when taken 3+ months (irreversible)

Question 33

Answer 33

Question 34

What is Domperidone?

Answer 34

a dopamine 2 antagonist (not readily available in the US). 10-20 mg TID

Can prolong the QT interval

Question 35