Delayed Gastric Emptying (Gastroparesis)

What is delayed gastric emptying?

After a meal the stomach mixes the food, breaks it into small pieces and passes it in a controlled way into the duodenum.

Gastroparesis is the passage of food from the stomach into the small intestine being slower than normal when there is no physical obstruction at the stomach outlet.

Patients often describe it as “what I eat stays in my stomach”, “I get full very quickly” or “my stomach is still full hours after eating”.

Gastroparesis ranges in severity from mild symptoms to conditions that seriously disturb nutrition.

Why does the stomach empty late?

Emptying of the stomach requires the muscles of the stomach, the nerves and the brain-gut system to work in a coordinated way.

A disturbance in this system may slow the movements of the stomach.

The important causes of gastroparesis include:

• Diabetes,
• Certain operations carried out around the stomach or the gullet,
• Certain drugs that affect the movements of the stomach,
• Certain neurological and systemic diseases.

In some patients no clear cause is found despite all investigation. This is called idiopathic gastroparesis.

Disturbances of gastric emptying, temporary or longer lasting, may also be seen after certain viral infections.

Which drugs can slow gastric emptying?

Some drugs may reduce the movements of the stomach.

Strong painkillers of the opioid group in particular, and certain other drugs, may cause gastroparesis-like symptoms or worsen existing gastroparesis.

GLP-1 receptor agonists, widely used in recent years for weight loss and for diabetes, may also slow gastric emptying.

It is not right for a person taking these drugs to stop them on their own initiative. If there are symptoms, the doctor managing the treatment should be consulted.

What are the symptoms?

The commonest complaints in gastroparesis are:

• Prolonged fullness after eating,
• Feeling full after very little food,
• Bloating,
• Nausea,
• Vomiting,
• Discomfort or pain in the upper abdomen,
• Loss of appetite.

Some patients may vomit food eaten hours earlier that is not yet digested.

In severe disease, inadequate nutrition, weight loss and fluid loss may develop.

In people with diabetes, irregular emptying of the stomach may also make blood sugar control more difficult.

Is all bloating gastroparesis?

No.

Bloating, early fullness, nausea and fullness after meals are common complaints and can arise in many different conditions.

Functional dyspepsia, peptic ulcer disease, the effects of certain drugs and conditions that narrow the stomach outlet can produce similar symptoms.

For this reason gastroparesis should not be diagnosed from the symptoms alone.

How is the diagnosis made?

Two things must be shown for a diagnosis of gastroparesis:

1. That there is no mechanical obstruction at the stomach outlet
2. That the emptying of the stomach is objectively shown genuinely to be delayed

Gastroscopy

Endoscopy can look for a stricture, an ulcer, a tumour or any other condition at the stomach outlet that might prevent food from passing.

Seeing food in the stomach at endoscopy may raise the suspicion of gastroparesis but does not on its own establish the diagnosis.

Gastric emptying scintigraphy

This is one of the most important methods for diagnosing gastroparesis.

The patient eats a standard meal containing a very small amount of a radioactive marker. Images are then taken at set times to measure how fast the food empties from the stomach.

In standard assessment, emptying is preferably followed for about four hours.

The method helps to show objectively whether emptying is genuinely delayed.

Other tests of gastric emptying may be used in some patients.

How is it treated?

Treatment is planned individually according to the cause and severity of the condition.

The aims of treatment are:

• To reduce nausea and vomiting,
• To make emptying of the stomach easier,
• To provide adequate nutrition,
• To prevent loss of fluid and electrolytes,
• To correct the underlying cause as far as possible.

How is nutrition arranged?

Nutrition is an important part of treatment.

In many patients:

• Taking smaller portions,
• Spreading meals through the day,
• Reducing very fatty foods,
• Limiting foods that are hard to digest, very fibrous or in large pieces,
• Chewing food well

may make emptying easier.

In marked gastroparesis in particular, foods in small particles, soft or where necessary liquidised, may be better tolerated.

But because unnecessary and severely restrictive diets can lead to weight loss and malnutrition, the nutrition plan should be arranged according to the patient’s condition.

Is there drug treatment?

Yes.

Some drugs speed up gastric emptying by increasing the movements of the stomach. These are called prokinetic drugs.

Metoclopramide is one of the drugs that can be used for this purpose. Because important neurological side effects such as involuntary movements can arise with long-term use, the duration and dose of treatment must be set by the doctor.

Antiemetic drugs may also be used to reduce nausea and vomiting.

The choice of drug is made according to the patient’s age, other illnesses, other medication and the severity of the gastroparesis.

Is endoscopic treatment possible?

Yes. Endoscopic options exist for selected patients whose disease resists treatment.

One of these is G-POEM (gastric peroral endoscopic myotomy).

In this procedure the pyloric muscle at the stomach outlet is treated endoscopically, with the aim of making the stomach empty more easily.

G-POEM is not applied to every patient with gastroparesis. It is considered in experienced centres for patients who have not responded adequately to standard treatment and who are thought to be suitable.

Surgical methods now arise in more selected situations.

What if feeding by mouth is not enough?

In severe gastroparesis the patient may not be able to take enough calories and fluid by mouth.

The necessary adjustments are made first so that feeding by mouth can continue.

If that is not possible, feeding methods that deliver nutrition beyond the stomach, into the small intestine, may be used in selected patients.

Intravenous feeding is generally reserved for particular situations where the other methods are not enough.

Does gastroparesis go away completely?

The course of the condition varies with its cause.

In some patients symptoms lessen over time. In others the condition continues for a long period and flares from time to time.

Gastroparesis is not generally a directly life-threatening condition; but in severe cases it may cause weight loss, malnutrition, fluid loss and worsening blood sugar control.

With a suitable diet, correction of the factors that may be causing the condition and, where needed, drug or interventional treatment, symptoms can be brought under control in a significant proportion of patients.

When should a doctor be consulted?

Prolonged early fullness, marked fullness after meals, and recurrent nausea or vomiting may call for gastroenterological assessment.

Medical assessment should be sought without delay where there is:

• Persistent or recurrent vomiting,
• Inability to keep food and fluids down,
• Marked weight loss,
• Severe or increasing abdominal pain,
• Vomiting of blood,
• Fainting or signs of serious fluid loss.

Currency: The information on this page was prepared for patients taking account of current international gastroenterological approaches to the diagnosis and treatment of gastroparesis.

This content is for general information. Gastroparesis should not be diagnosed from symptoms alone; mechanical obstruction must be excluded and, in patients where it is needed, gastric emptying assessed by objective methods.