Gastroparesis

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Synonyms

delayed gastric emptying, gastric atony, gastric dysmotility, gastrointestinal autonomic neuropathy, gastroparesis diabeticorum, severe functional dyspepsia,

Overview

Gastroparesis, which means stomach paralysis, is a condition affecting the nerves and muscles in your stomach. It interferes with the muscle activity (peristalsis) that moves food through your stomach and into your small intestine. When your stomach muscles and nerves can’t activate correctly, your stomach can’t process food or empty itself as it should. This holds up your whole digestive process.

People with gastroparesis have uncomfortable symptoms during digestion, and they can also have longer-lasting side effects. They might have low appetite and trouble meeting their nutritional needs, or trouble controlling their blood sugar. When food finally passes from their stomach, it may not pass completely and may leave some behind. This can develop into a hardened, solid mass called a bezoar.

Symptoms

Common symptoms include:

  • Indigestion.
  • Bloated stomach.
  • Feeling full very quickly and/or for a long time.
  • Upper abdominal pain.
  • Nausea and vomiting.
  • Regurgitating (spitting up) whole pieces of undigested food.
  • Loss of appetite.
  • Acid reflux and heartburn.
  • Blood sugar fluctuations.
  • Constipation.

Causes

Diabetes

Around one-third of people with diabetes (Type 1 or Type 2) develop gastroparesis. Diabetes-related gastroparesis is a type of diabetes-related neuropathy. It happens when high blood sugar levels damage your nerves. High blood sugar levels also damage the blood vessels that carry oxygen to your tissues, so your stomach nerves and muscles are both affected.

Surgery

Surgery on or near your stomach can injure the vagus nerve that runs through your stomach and coordinates its movements. Post-surgical gastroparesis can develop any time after surgery. Sometimes it happens right away, but it can also develop months (or even years) later. Common surgical procedures that have caused post-surgical gastroparesis include:

  • Nissen fundoplication.
  • Gastrectomy.
  • Gastric bypass surgery.
  • Pancreatectomy.
  • Vagotomy.
  • Cholecystectomy.
Infections

Gastrointestinal infections can trigger gastroparesis. Viral infections such as norovirus and rotavirus are more common causes, but bacterial infections can cause it too. Scientists aren’t sure whether it’s the infections themselves that damage your stomach nerves or if the immune cells meant to kill the infection damage your nerves by mistake.

Autoimmune disease

In autoimmune disease, your immune system sends antibodies to attack your own body cells, mistaking them for an infection. New research indicates that these autoantibodies may damage the nerves in your stomach. You may have autoimmune gastroparesis even if you have no other symptoms of autoimmune disease, or if your other symptoms are unrelated to your stomach.

Drugs

Certain medications and recreational drugs can block the nerve signals that activate your stomach muscles. This can lead to temporary gastroparesis. Some of these medications are prescribed for conditions also linked to gastroparesis, such as diabetes. If you already have gastroparesis, or you’ve had it before, these are medications to avoid. They include:

  • Opioids (narcotics).
  • Nicotine.
  • Marijuana.
  • Tricyclic antidepressants.
  • Progesterone.
  • Anticholinergics (allergy medications).
  • Calcium channel blockers (for high blood pressure).
  • Amylin analogs / GLP-1 antagonists (to treat Type 2 diabetes).
  • Cyclosporine (to prevent organ transplant rejection).
  • Clonidine (to treat high blood pressure).
  • Lithium (to treat bipolar disorder).
  • Antipsychotic medications.
Other causes

Less common causes of gastroparesis include:

  • Neurological diseases. Conditions affecting your nervous system may cause your stomach nerves to malfunction, like Parkinson’s disease, multiple sclerosis or autonomic dysfunction.
  • Collagen-vascular diseases. Chronic inflammatory connective tissues diseases can degenerate your stomach muscles, including amyloidosis, scleroderma, lupus and Ehlers-Danos syndrome.
  • Endocrine disorders. Conditions affecting your endocrine system can cause chemical nerve damage, including thyroid disease, adrenal disorders, electrolyte imbalances and kidney failure.
  • Cystic fibrosis. Cystic fibrosis causes mucus to build up in your gastrointestinal tract, slowing down motility throughout. An estimated one-third of people with CF have gastroparesis.

Treatment

Healthcare providers can’t directly fix the damage that causes gastroparesis, but they can offer treatment to stimulate muscle contractions in your stomach and encourage it to empty. Medications are the first-line treatment, with surgery reserved for those who don’t respond to medications or can’t take them. All of the treatments have potential side effects, and no one treatment works for everyone.

The goals of treatment are to:

  • Stimulate your stomach muscles and/or allow your stomach to empty.
  • Make sure your body has the nutrition and hydration it needs.
  • Manage symptoms and side effects of the condition.
  • Manage the cause, if possible, to prevent it from getting worse.

Your treatment plan may include:

  • Medications.
  • Nutrition/hydration therapy.
  • Surgery.
  • Specific treatments for the condition causing your gastroparesis.

Medications

Prokinetics, medications that stimulate gastrointestinal motility, are the first-line treatment for gastroparesis. Prokinetics include:

  • Metoclopramide. This is the only FDA-approved medication to treat gastroparesis. It stimulates muscle contractions in your stomach and can also help relieve nausea. However, it comes with a black-label warning because it can cause neurological side effects, including tremors and muscle twitching.
  • Motolin agonists. Motolin agonists are an alternative type of prokinetic drug that your provider might suggest. They include erythromycin and azithromycin. They’re normally used as antibiotics, but healthcare providers do prescribe them for off-label treatment of gastroparesis.
  • Serotonin agonists. Tegaserod and prucalopride are two serotonin agonists that are normally prescribed to stimulate your bowels to improve constipation. They haven’t been fully evaluated for treating gastroparesis, but some healthcare providers prescribe them for that use.
  • Dopamine antagonists. A drug called domperidone can improve gastric motility and nausea by blocking a neurotransmitter called dopamine. It’s not normally available in the U.S., but U.S. healthcare providers can apply for expanded access to the drug to prescribe it for gastroparesis.

Additional medications may include:

  • Antiemetics to control nausea and vomiting.
  • Proton pump inhibitors to treat acid reflux.
  • Pain relievers for significant stomach pain.
  • Diabetes medications to manage blood sugar.
Nutrition

You might need to change your diet to accommodate your condition — for example, eat less fiber and less fat to make digestion easier. You might also need more specific nutritional therapy to replace missing nutrients. Your provider might prescribe dietary supplements, or even temporary tube feeding or IV feeding. Some people may need IV fluids to rehydrate and correct electrolyte imbalances.

Surgery

Surgery is the last resort in gastroparesis treatment. If all other treatments fail, you might need surgery to modify your stomach to help food pass through it. Procedures to modify your stomach include:

  • Pyloroplasty. Pyloroplasty modifies your pylorus, the muscular valve at the bottom of your stomach that lets food empty out of it. Most pyloroplasties involve cutting into the pylorus muscle to relax and expand the opening. The most recent variation, called the G-POEM, is an endoscopic surgical procedure. That means that instead of cutting into your abdomen to access your stomach, a surgeon operates through an endoscope, a long tube passed through your mouth into your stomach. G-POEM stands for “gastric peroral endoscopic myotomy.” Translated, that means “in-the-stomach, through-the-mouth, by-endoscope muscle incision.”
  • Gastric bypass. Some people may need to bypass the lower portion of their stomach completely, either because it’s no longer functional or because this procedure is more likely to succeed for them. The procedure involves a partial gastrectomy — removing or closing off part of your stomach — and creating a new outlet from your stomach to your small intestine (gastrojejunostomy). Gastric bypass is commonly offered as a weight loss surgery, especially for people with Type 2 diabetes related to obesity, and it can have dramatic effects on both conditions. Your provider might recommend it for severe diabetes-related gastroparesis.