Updated: 5/22/2019

Diabetic Gastroparesis

Review Topic
  • A 56-year-old woman presents to the emergency clinic for recurrent nausea and vomiting for the past 3 weeks. On average, these episodes occur after food intake, which the patient reports, has significantly decreased in amount as she now feels full quickly. Her past medical history is significant for poorly-controlled diabetes for the past 10 years. A physical examination demonstrates epigastric distention and tenderness with no peritoneal signs.
  • Clinical definition
    • syndrome of delayed gastric emptying in the absence of a mechanical obstruction and the presence of cardinal symptoms (e.g., nausea) secondary to diabetes mellitus (DM)
    • other causes of gastroparesis includes
      • idiopathic
      • viral infection (e.g., cytomegalovirus)
      • medications (e.g., tricyclic antidepressants)
      • postsurgical
  • Epidemiology
    • demographics
      • DM is the most common systemic disease associated with gastroparesis
      • symptoms of gastroparesis are reported in 11-18% of patients with DM
    • risk factors
      • typically occurs in patients who have had DM for over 5 years
      • chronic hyperglycemia (blood glucose > 200mg/dL)   
  • Pathogenesis
    • abnormalities of antral motor function and coordination and postprandial proximal gastric accommodation and contraction
      • primarily due to autonomic dysfunction and/or abnormal intrinsic nervous system (e.g., interstitial cells of Cajal, the pacemaker of the gut)
      • other proposed contributing factors 
        • hyperglycemia
        • vagal dysfunction
        • loss of neural nitric oxide synthase (nNOS) expression
        • oxidative stress
  • Symptoms 
    • nausea 
    • vomiting
    • abdominal pain  
    • early satiety  
    • postprandial fullness
    • bloating
    • weight loss if severe
  • Physical exam
    • epigastric distension/tenderness
    • succession splash
    • other signs of autonomic dysfunction (e.g., orthostatic hypotension)
  • Diagnostic testing
    • diagnostic approach
      • diagnosis is based on clinical presentation and confirmed with gastric emptying studies
    • imaging
      • upper gastrointestinal endoscopy
        • initial test performed to exclude mechanical obstruction
        • alternative options include computed tomographic (CT) or magnetic resonance (MR) enterography
      • scintigraphic gastric emptying
        • most cost effective and widely available technique to confirm delayed gastric emptying
        • usually evaluates the gastric emptying of solids
    • studies
      • laboratory studies
        • HbA1c for assessment of glycemic control
        • other tests such as hemoglobin, TSH, ANA, and albumin for evaluation of other etiologies
  • Psychiatric disease 
    • distinguishing factors
      • patients may have a history of psychiatric disease (e.g., bulimia)
      • some patients may have a normal scintigraphic emptying study
  • Cyclic vomiting syndrome 
    • distinguishing factors
      • clinical presentation of intense vomiting episodes separated by symptom-free periods
      • history of cannabinoid use
  • First-line
    • dietary modification (for patients with mild disease)
      • avoid foods that are fatty, acidic, spicy, and roughage-based
      • avoid alcohol and smoking
    • optimization of glycemic control
      • acute hyperglycemia has been demonstrated to slow gastric emptying
    • if continued symptoms, pharmacologic therapy with prokinetic and antiemetics
      • metoclopramide is the first-line prokinetic  
      • second-line prokinetics includes domperidone, erythromycin, and cisapride
      • antiemetics include diphenhydramine, ondansetron, and prochlorperazine
  • Second-line
    • indicated in patients with refractory symptoms despite first-line therapy
    • endoscopic gastrostomy tube decompression and jejunal feeding tube
    • surgical treatments
    • tricyclic antidepressants (low-dose nortriptyline)
  • Electrolyte imbalance
  • Malnutrition

Please rate topic.

Average 5.0 of 1 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Topic COMMENTS (0)
Private Note