Background

Gastroparesis is a medical condition characterized by delayed emptying of the stomach contents into the small intestine. The word “gastroparesis” is derived from the Greek word’s “gastro” meaning stomach and “paresis” meaning partial paralysis. It is also known as delayed gastric emptying.

In a healthy digestive system, the muscles of the stomach contract to help break down food and move it along the gastrointestinal tract. However, in individuals with gastroparesis, the muscles in the stomach become weak or malfunctioning, leading to impaired motility and delayed emptying of food.

Epidemiology

The epidemiology of gastroparesis provides insights into the prevalence, incidence, and demographic characteristics of individuals affected by this condition. However, it’s worth noting that specific epidemiological data on gastroparesis can vary due to differences in study populations, diagnostic criteria, and data collection methods. Nevertheless, here is an overview of the available information:

• Prevalence: The exact prevalence of gastroparesis is difficult to determine due to the variability in symptoms and challenges in diagnosis. Estimates suggest that gastroparesis affects approximately 0.2% to 2% of the general population. However, in specific patient populations, such as individuals with diabetes, the prevalence is higher. Among individuals with diabetes, the prevalence of gastroparesis is estimated to be around 5% to 12%.
• Incidence: The incidence of gastroparesis refers to the rate at which new cases of the condition are diagnosed within a specific population over a given time period. Unfortunately, accurate incidence data for gastroparesis are limited. However, some studies suggest that the incidence of gastroparesis is increasing, possibly due to factors such as the rising prevalence of diabetes and improved awareness and diagnostic techniques.
• Demographic Characteristics: Gastroparesis can affect individuals of all ages, including children and adults. However, certain demographic characteristics have been associated with a higher risk of developing the condition:
• Gender: Gastroparesis appears to be more common in women compared to men. Studies indicate that women account for approximately 80% of gastroparesis cases.
• Diabetes: As mentioned earlier, diabetes is a significant risk factor for developing gastroparesis. Individuals with type 1 or type 2 diabetes are more likely to develop gastroparesis compared to those without diabetes.
• Age: Gastroparesis can occur at any age, but it appears to be more prevalent in individuals in their 30s, 40s, and 50s. However, cases have been reported across all age groups.
• Other Medical Conditions: Gastroparesis can also occur in individuals with other medical conditions, such as neurological disorders, connective tissue disorders, and post-surgical gastroparesis.

Anatomy

Pathophysiology

The pathophysiology of gastroparesis involves abnormalities in the normal functioning of the stomach muscles and the nerves that control them. While the exact mechanisms can vary, the following are key factors involved:

• Impaired Gastric Motility: In individuals with gastroparesis, the stomach muscles responsible for contractions (gastric motility) are weakened or damaged. These contractions help break down food and propel it through the stomach into the small intestine for further digestion and absorption. In gastroparesis, these contractions become inefficient or fail to occur, leading to delayed gastric emptying.
• Vagus Nerve Dysfunction: The vagus nerve plays a crucial role in regulating gastrointestinal motility. It controls the coordinated contractions of the stomach muscles necessary for proper digestion. Damage or dysfunction of the vagus nerve is a common cause of gastroparesis. This can occur due to conditions such as diabetes, where high blood sugar levels can cause nerve damage (diabetic neuropathy).
• Loss of Interstitial Cells of Cajal (ICC): Interstitial cells of Cajal are specialized cells located in the muscular layer of the gastrointestinal tract. They act as pacemakers, generating electrical signals that coordinate muscle contractions. In gastroparesis, there may be a reduction in the number or dysfunction of ICCs, leading to disrupted electrical signals and impaired gastric motility.
• Hormonal Imbalances: Several hormones play a role in regulating stomach emptying. Gastroparesis can disrupt the normal release and action of these hormones. For example, the hormone ghrelin stimulates stomach contractions and motility, while peptide YY (PYY) inhibits gastric emptying. Imbalances in these hormones can contribute to delayed gastric emptying.
• Autoimmune and Inflammatory Factors: In some cases, gastroparesis may be associated with autoimmune conditions or inflammatory processes. Autoimmune gastroparesis is characterized by the immune system mistakenly attacking the cells in the stomach responsible for muscle contractions, leading to impaired motility.

Overall, the pathophysiology of gastroparesis involves a complex interplay of factors affecting stomach muscle function, neural regulation, hormonal balance, and potential immune system involvement. These abnormalities lead to delayed gastric emptying and the characteristic symptoms of gastroparesis, such as nausea, vomiting, and bloating.

It is important to note that the pathophysiology of gastroparesis can vary between individuals, and not all mechanisms may be present in every case. Additionally, research is ongoing to further understand the underlying causes and pathophysiological processes involved in this condition.

Etiology

Gastroparesis can have various etiologies, and in some cases, the cause may remain unknown. Here are some common factors and conditions associated with the development of gastroparesis:

• Diabetes: Diabetes is the most common known cause of gastroparesis. High blood sugar levels can damage the vagus nerve, which controls the muscles in the stomach. Damage to the vagus nerve disrupts the normal coordination of stomach contractions, leading to gastroparesis.
• Idiopathic: Idiopathic gastroparesis refers to cases where the cause of gastroparesis is unknown. It accounts for a significant portion of gastroparesis cases. The exact mechanisms leading to idiopathic gastroparesis are not well understood, but it is believed that a combination of factors, including abnormalities in the nerves and muscles of the stomach, may contribute to its development.
• Post-surgical Gastroparesis: Some individuals may develop gastroparesis following surgeries that involve the stomach or upper gastrointestinal tract. Surgical procedures, such as gastric bypass surgery or fundoplication, can disrupt the normal functioning of the stomach and its motility, leading to gastroparesis.
• Neurological Disorders: Certain neurological conditions can be associated with gastroparesis. Examples include Parkinson’s disease, multiple sclerosis, stroke, and autonomic neuropathies. These conditions can affect the nerves that control stomach motility, resulting in gastroparesis.
• Connective Tissue Disorders: Disorders affecting the connective tissue, such as Ehlers-Danlos syndrome or systemic sclerosis, have been linked to gastroparesis. These conditions can affect the muscles and connective tissue in the gastrointestinal tract, leading to impaired stomach emptying.
• Medications and Substances: Certain medications can slow down gastric motility and contribute to gastroparesis. Opioids, calcium channel blockers, tricyclic antidepressants, and some anti-nausea medications are examples of drugs that can cause or exacerbate gastroparesis symptoms. Additionally, excessive alcohol consumption or substance abuse can also affect stomach motility.
• Viral Infections: In some cases, viral infections, particularly those caused by certain strains of the herpes virus or Epstein-Barr virus, have been associated with the development of gastroparesis. These infections can cause inflammation and damage to the nerves controlling stomach function.

Genetics

Prognostic Factors

The prognosis of gastroparesis can vary widely depending on several factors, including the underlying cause, the severity of symptoms, and the effectiveness of treatment. While gastroparesis is a chronic condition that often requires long-term management, many individuals can achieve symptom control and maintain a good quality of life with appropriate treatment and lifestyle modifications. However, in some cases, gastroparesis can be challenging to manage, leading to persistent symptoms and complications.

Here are some factors that can influence the prognosis of gastroparesis:

• Underlying Cause: The prognosis may depend on the underlying cause of gastroparesis. Gastroparesis associated with diabetes tends to have a more chronic course and may be more difficult to manage than idiopathic gastroparesis (without a known cause) or gastroparesis related to other factors.
• Symptom Severity: The severity of symptoms can vary from mild to severe in gastroparesis. Individuals with milder symptoms generally have a better prognosis, as they may respond well to dietary modifications and medical therapies. However, individuals with severe symptoms that significantly impact daily life and lead to malnutrition or weight loss may have a more guarded prognosis and require more aggressive treatment approaches.
• Response to Treatment: The prognosis can be influenced by the effectiveness of treatment interventions. Some individuals may experience significant symptom relief and improved gastric emptying with dietary modifications, medication, or surgical interventions. However, others may have a poor response to treatment or experience side effects from medications, requiring alternative approaches and potentially impacting the prognosis.
• Complications: Gastroparesis can lead to various complications, such as malnutrition, weight loss, dehydration, electrolyte imbalances, and gastrointestinal obstruction. The presence of complications can worsen the prognosis and may require additional interventions or hospitalizations to manage these issues effectively.
• Underlying Health Conditions: The presence of other comorbidities, such as diabetes, autoimmune disorders, or neurological conditions, can influence the overall prognosis of gastroparesis. Coexisting medical conditions may complicate the management of gastroparesis and affect the response to treatment.
• Patient Adherence: Patient adherence to treatment recommendations, including dietary modifications, medication regimen, and follow-up appointments, can impact the prognosis. Active participation and collaboration with healthcare professionals in managing the condition are crucial for achieving optimal outcomes.

Clinical History

Clinical history

When evaluating a patient with suspected gastroparesis, the clinical history plays a crucial role in understanding the patient’s symptoms, identifying potential risk factors, and guiding further diagnostic investigations. Here are some key aspects of the clinical history for gastroparesis:

• Gastrointestinal Symptoms: Patients with gastroparesis typically present with gastrointestinal symptoms related to delayed gastric emptying. These symptoms may include chronic or recurrent nausea, vomiting (often undigested food several hours after eating), bloating, early satiety (feeling full quickly), abdominal pain or discomfort, and a sense of fullness even after consuming small amounts of food.
• Meal-related Symptoms: Assessing how symptoms correlate with meals is important. Gastroparesis symptoms often worsen after eating solid foods, especially those high in fat and fiber. Patients may notice symptom exacerbation with specific types of foods or meals. They might also experience symptom relief after fasting or consuming liquid or easily digestible foods.
• Duration and Progression: Determine the duration of symptoms and their progression over time. Gastroparesis symptoms are typically chronic or recurrent, with varying severity and periods of remission or exacerbation. Understanding the pattern of symptom progression can help differentiate gastroparesis from acute or self-limiting conditions.
• Associated Factors: Inquire about any factors that worsen or alleviate symptoms. For example, patients may report worsening symptoms with stress, certain medications (such as opioids or anticholinergics), or hormonal changes (in women during menstruation). Conversely, some patients may find relief from symptoms by adopting specific dietary modifications or by taking medications that promote gastric emptying.
• Underlying Medical Conditions: Assess the presence of any underlying medical conditions associated with gastroparesis, such as diabetes, autoimmune disorders, neurological conditions (e.g., Parkinson’s disease, multiple sclerosis), or connective tissue disorders (e.g., Ehlers-Danlos syndrome, systemic sclerosis). These conditions may provide clues to the etiology of gastroparesis.
• Medication History: Obtain a comprehensive medication history, including prescription medications, over-the-counter drugs, and any recent changes or additions to the medication regimen. Some medications, such as opioids, calcium channel blockers, and tricyclic antidepressants, can slow gastric motility and contribute to gastroparesis symptoms.
• Previous Surgeries or Procedures: Inquire about any history of gastric or upper gastrointestinal surgeries, such as gastric bypass surgery, fundoplication, or previous procedures involving the stomach or vagus nerve. These surgeries can impact gastric motility and potentially lead to gastroparesis.
• Impact on Quality of Life: Assess the impact of gastroparesis symptoms on the patient’s daily activities, work, social life, and overall quality of life. Gastroparesis can significantly affect a patient’s ability to eat, digest food properly, and maintain nutrition, leading to weight loss, malnutrition, and emotional distress.
• Family History: Although the exact cause of gastroparesis is often unknown, there may be a genetic component or a familial predisposition. Inquire about any family history of gastrointestinal motility disorders or related conditions.

Physical Examination

Physical examination

The physical examination for gastroparesis aims to assess the patient’s general condition, abdominal findings, and signs that may suggest complications or related conditions. While the physical examination alone is not diagnostic for gastroparesis, it can provide important clinical clues. Here are some key aspects of the physical examination in gastroparesis:

• General Appearance: Evaluate the patient’s overall appearance, including their level of distress, signs of malnutrition or weight loss, and signs of dehydration (such as dry mucous membranes or decreased skin turgor).
• Vital Signs: Measure the patient’s blood pressure, heart rate, and respiratory rate. Note any abnormalities that may suggest autonomic dysfunction, which can be associated with gastroparesis in some cases.
• Abdominal Examination: Perform a thorough examination of the abdomen. The following aspects are important to assess:
• Inspection: Look for any abdominal distension or visible peristaltic waves (rhythmic contractions of the stomach that may be absent or altered in gastroparesis).
• Auscultation: Listen to bowel sounds with a stethoscope. In gastroparesis, bowel sounds may be diminished or absent due to impaired gastric motility. However, the absence of bowel sounds alone does not confirm the diagnosis of gastroparesis.
• Palpation: Palpate the abdomen gently to assess for tenderness, distension, or the presence of any masses. Note any areas of discomfort or pain that may indicate underlying conditions, such as pancreatitis or an abdominal abscess.
• Percussion: Percuss the abdomen to detect any abnormal findings, such as dullness suggestive of ascites (accumulation of fluid in the abdominal cavity).
• Skin and Mucous Membranes: Examine the skin and mucous membranes for signs of dehydration, malnutrition, or other systemic conditions associated with gastroparesis, such as skin changes seen in connective tissue disorders.
• Neurological Examination: Depending on the clinical presentation and suspected underlying cause, perform a focused neurological examination to assess for any signs of peripheral neuropathy, autonomic dysfunction, or other neurological abnormalities that may be associated with gastroparesis.

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Differential diagnosis

Gastroparesis shares symptoms with several other conditions, making its diagnosis challenging. Differential diagnosis involves considering other conditions that can cause similar symptoms. Here are some conditions that should be considered during the differential diagnosis of gastroparesis:

• Gastroesophageal Reflux Disease (GERD): GERD is a condition where stomach acid flows back into the esophagus, causing symptoms such as heartburn, regurgitation, and chest pain. While both GERD and gastroparesis can cause similar symptoms like nausea and vomiting, GERD typically presents with acid reflux symptoms that are not commonly seen in gastroparesis.
• Peptic Ulcer Disease (PUD): PUD refers to the presence of open sores (ulcers) in the lining of the stomach or the upper part of the small intestine. Symptoms of PUD include abdominal pain, nausea, and vomiting, which can overlap with gastroparesis. However, PUD is characterized by a different underlying pathology, often associated with infection by Helicobacter pylori or prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs).
• Functional Dyspepsia: Functional dyspepsia is a condition characterized by recurrent upper abdominal discomfort or pain, early satiety, and bloating. These symptoms are similar to gastroparesis, but in functional dyspepsia, there is no evidence of delayed gastric emptying. It is primarily a disorder of gut hypersensitivity and altered gastrointestinal motility.
• Irritable Bowel Syndrome (IBS): IBS is a chronic disorder that affects the large intestine and causes symptoms such as abdominal pain, bloating, and altered bowel habits. While IBS primarily affects the lower gastrointestinal tract, some individuals with IBS may experience upper gastrointestinal symptoms that can mimic gastroparesis. Differentiating between IBS and gastroparesis often requires a careful evaluation of the predominant symptoms and diagnostic tests.
• Small Intestinal Bacterial Overgrowth (SIBO): SIBO is a condition characterized by an overgrowth of bacteria in the small intestine. Symptoms include abdominal pain, bloating, diarrhea, and malabsorption. SIBO can sometimes cause symptoms similar to gastroparesis, but it primarily affects the small intestine rather than the stomach.
• Pancreatic Disorders: Pancreatic diseases, such as chronic pancreatitis or pancreatic cancer, can cause symptoms similar to gastroparesis, including abdominal pain, nausea, and vomiting. These conditions often have additional specific symptoms related to pancreatic dysfunction, such as steatorrhea (fatty stools) or abnormal pancreatic enzyme levels.
• Other Gastric Motility Disorders: Conditions such as chronic intestinal pseudo-obstruction (CIPO), rapid gastric emptying (dumping syndrome), or intestinal dysmotility syndromes can present with symptoms similar to gastroparesis. Distinguishing between these conditions often requires specialized diagnostic tests, such as gastric emptying studies or manometry.

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

The treatment of gastroparesis aims to alleviate symptoms, improve gastric emptying, and enhance the patient’s overall quality of life. The approach to treatment can involve various strategies, including dietary and lifestyle modifications, medications, and in some cases, surgical interventions. The specific treatment plan depends on the severity of symptoms, underlying causes, and individual patient factors. Here are some common approaches to the treatment of gastroparesis:

Dietary Modifications:

• Eating smaller, more frequent meals: Consuming smaller portions of food more frequently throughout the day can help reduce the workload on the stomach and facilitate digestion.
• Soft or pureed foods: Opting for easily digestible foods, such as well-cooked vegetables, blended soups, or smoothies, can be better tolerated by individuals with gastroparesis.
• Low-fiber diet: Reducing the intake of high-fiber foods, such as whole grains, raw fruits and vegetables, and legumes, can help minimize symptoms of gastroparesis.
• Liquid diet: In severe cases, a temporary or long-term liquid diet may be recommended to ensure adequate nutrition and improve symptom control.

Medications:

• Prokinetic agents: Medications that enhance gastric motility, such as metoclopramide or domperidone, are commonly prescribed to improve stomach emptying in gastroparesis. These medications work by stimulating the muscles of the stomach and reducing nausea and vomiting.
• Antiemetics: Anti-nausea medications, such as ondansetron or promethazine, may be prescribed to help manage symptoms of nausea and vomiting.
• Medications for symptom relief: Other medications, such as prochlorperazine or lorazepam, may be used to alleviate specific symptoms like nausea, vomiting, or abdominal pain.

Enteral Nutrition:

In cases of severe gastroparesis or when oral intake is inadequate, enteral nutrition may be necessary. This involves delivering liquid nutrition directly into the small intestine through a feeding tube. This approach ensures adequate nutrition while bypassing the stomach.

Surgical Interventions:

• Gastric Electrical Stimulation (GES): GES involves the implantation of a device that delivers electrical impulses to the stomach muscles, aiming to improve gastric emptying and alleviate symptoms. It may be considered in individuals with refractory symptoms who have not responded to conservative treatments.
• Gastrostomy or Jejunostomy Tube Placement: In severe cases where oral intake is severely impaired and enteral nutrition is necessary, the placement of a feeding tube directly into the stomach (gastrostomy) or the jejunum (jejunostomy) may be considered.

Diabetes Management:

For individuals with diabetic gastroparesis, optimizing blood sugar control is crucial. Close management of diabetes through lifestyle modifications, medication adjustments, or insulin therapy can help minimize the impact of high blood sugar on gastric motility.

Symptom Management:

Anti-reflux measures: If gastroesophageal reflux is present, medications to reduce acid production (e.g., proton pump inhibitors) or lifestyle modifications to minimize acid reflux can be recommended. Symptomatic relief: Various measures, such as elevation of the head during sleep, avoiding lying down after meals, and stress management techniques, may help alleviate symptoms.

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Medication

Future Trends

Media Gallary

References

https://www.ncbi.nlm.nih.gov/books/NBK551528/