Gastroparesis

National Digestive Diseases Information Clearinghouse

What is gastroparesis? Gastroparesis, also called delayed gastric emptying, is a disorder that slows or stops the movement of food from the to the U.S. Department of Health and small intestine. Normally, the muscles of the Human Services stomach, which are controlled by the , contract to break up food and move it NATIONAL through the gastrointestinal (GI) tract. The INSTITUTES OF HEALTH GI tract is a series of hollow organs joined in a long, twisting tube from the mouth to the Stomach anus. The movement of muscles in the GI tract, along with the release of hormones and enzymes, allows for the digestion of food. Gastroparesis can occur when the vagus nerve is damaged by illness or injury and the stomach muscles stop working normally. Food then moves slowly from the stom- ach to the small intestine or stops moving Small Jejunum altogether. intestine

What causes gastroparesis? Gastroparesis slows or stops the movement of food Most people diagnosed with gastroparesis from the stomach to the small intestine. have idiopathic gastroparesis, which means a health care provider cannot identify the cause, even with medical tests. is causes of gastroparesis include intestinal the most common known cause of gastropa- surgery and nervous system diseases such as resis. People with diabetes have high levels Parkinson’s disease or multiple sclerosis. For of blood glucose, also called blood sugar. reasons that are still unclear, gastroparesis Over time, high blood glucose levels can is more commonly found in women than in damage the vagus nerve. Other identifiable men. What are the symptoms of How is gastroparesis gastroparesis? diagnosed? The most common symptoms of gastropa- Gastroparesis is diagnosed through a physi- resis are , a feeling of fullness after cal exam, medical history, blood tests, tests eating only a small amount of food, and to rule out blockage or structural problems undigested food—sometimes sev- in the GI tract, and gastric emptying tests. eral hours after a meal. Other symptoms of Tests may also identify a nutritional disorder gastroparesis include or underlying disease. To rule out any block- age or other structural problems, the health • gastroesophageal reflux (GER), also care provider may perform one or more of called acid reflux or acid regurgitation— the following tests: a condition in which stomach contents flow back up into the esophagus, the • Upper gastrointestinal (GI) endos- organ that connects the mouth to the copy. This procedure involves using stomach an endoscope—a small, flexible tube with a light—to see the upper GI tract, • pain in the stomach area which includes the esophagus, stomach, • abdominal and —the first part of the • lack of appetite small intestine. The test is performed at a hospital or outpatient center by Symptoms may be aggravated by eating a gastroenterologist—a doctor who greasy or rich foods, large quantities of specializes in digestive diseases. The foods with fiber—such as raw fruits and endoscope is carefully fed down the vegetables—or drinking beverages high in esophagus and into the stomach and fat or carbonation. Symptoms may be mild duodenum. A small camera mounted or severe, and they can occur frequently in on the endoscope transmits a video some people and less often in others. The image to a monitor, allowing close symptoms of gastroparesis may also vary in examination of the intestinal lining. A intensity over time in the same individual. person may receive a liquid anesthetic Sometimes gastroparesis is difficult to diag- that is gargled or sprayed on the back of nose because people experience a range of the throat. An intravenous (IV) needle symptoms similar to those of other diseases. is placed in a vein in the arm if general anesthesia is given. The test may show blockage or large —solid col- lections of food, mucus, vegetable fiber, hair, or other material that cannot be digested in the stomach—that are some- times softened, dissolved, or broken up during an upper GI endoscopy.

2 Gastroparesis • Upper GI series. An upper GI series • Gastric emptying scintigraphy. The test may be done to look at the small intes- involves eating a bland meal—such as tine. The test is performed at a hospital eggs or an egg substitute—that contains or outpatient center by an x-ray techni- a small amount of radioactive material. cian, and the images are interpreted The test is performed in a radiology by a radiologist—a doctor who special- center or hospital by a specially trained izes in medical imaging. Anesthesia technician and interpreted by a radi- is not needed. No eating or drinking ologist; anesthesia is not needed. An is allowed for 8 hours before the pro- external camera scans the abdomen to cedure, if possible. If the person has show where the radioactive material is diabetes, a health care provider may located. The radiologist is then able to give different instructions about fasting measure the rate of gastric emptying at before the test. During the procedure, 1, 2, 3, and 4 hours after the meal. If the person will stand or sit in front of more than 10 percent of the meal is still an x-ray machine and drink barium, a in the stomach at 4 hours, the diagnosis chalky liquid. Barium coats the small of gastroparesis is confirmed. intestine, making signs of gastroparesis • SmartPill. The SmartPill is a small show up more clearly on x rays. Gastro- electronic device in capsule form. The is likely if the x ray shows food SmartPill test is available at specialized in the stomach after fasting. A person outpatient centers. The images are may experience bloating and nausea for interpreted by a radiologist. The device a short time after the test. For several is swallowed and moves through the days afterward, barium liquid in the entire digestive tract, sending infor- GI tract causes stools to be white or mation to a cell-phone-sized receiver light colored. A health care provider worn around the person’s waist or neck. will give the person specific instructions The recorded information provides a about eating and drinking after the test. detailed record of how quickly food • Ultrasound. Ultrasound uses a device, travels through each part of the diges- called a transducer, that bounces safe, tive tract. painless sound waves off organs to cre- • Breath test. With this test, the person ate an image of their structure. The eats a meal containing a small amount procedure is performed in a health care of radioactive material; then breath provider’s office, outpatient center, or samples are taken over a period of hospital by a specially trained techni- several hours to measure the amount cian, and the images are interpreted by of radioactive material in the exhaled a radiologist; anesthesia is not needed. breath. The results allow the health The images can show whether gallblad- care provider to calculate how fast the der disease and could be stomach is emptying. the cause of a person’s digestive symp- toms, rather than gastroparesis.

3 Gastroparesis How is gastroparesis helps improve symptoms. Puréed fresh or cooked fruits and vegetables can be incorpo- treated? rated into shakes and soups. A health care Treatment of gastroparesis depends on the provider may recommend a dietitian to help severity of the person’s symptoms. In most a person plan meals that minimize symptoms cases, treatment does not cure gastroparesis, and ensure all nutritional needs are met. which is usually a chronic, or long-lasting, condition. Gastroparesis is also a relapsing When the most extreme cases of gastropa- condition—the symptoms can come and go resis lead to severe nausea, vomiting, and for periods of time. Treatment helps people dehydration, urgent care may be required manage the condition so they can be as com- at a medical facility where IV fluids can be fortable and active as possible. given. Eating, Diet, and Nutrition Medications Changing eating habits can sometimes help Several prescription medications are avail- control the severity of gastroparesis symp- able to treat gastroparesis. A combination toms. A health care provider may suggest of medications may be used to find the most eating six small meals a day instead of three effective treatment. large ones. If less food enters the stomach (Reglan). This medication each time a person eats, the stomach may not stimulates stomach muscle contractions to become overly full, allowing it to empty more help with gastric emptying. Metoclopramide easily. Chewing food well, drinking non- also helps reduce nausea and vomiting. The carbonated liquids with a meal, and walking medication is taken 20 to 30 minutes before or sitting for 2 hours after a meal—instead meals and at bedtime. Possible side effects of lying down—may assist with gastric of metoclopramide include fatigue, sleepi- emptying. ness, and depression. Currently, this is the A health care provider may also recom- only medication approved by the FDA for mend avoiding high-fat and fibrous foods. treatment of gastroparesis. However, the Fat naturally slows digestion and some raw FDA has placed a black box warning on vegetables and fruits are more difficult to this medication because of rare reports of it digest than other foods. Some foods, such as causing an irreversible neurologic side effect oranges and broccoli, contain fibrous parts called tardive dyskinesia—a disorder that that do not digest well. People with gastro- affects movement. paresis should minimize their intake of large . This antibiotic, prescribed portions of these foods because the undi- at low doses, may improve gastric emptying. gested parts may remain in the stomach too Like metaclopramide, erythromycin works by long. Sometimes, the undigested parts form increasing the contractions that move food bezoars. through the stomach. Possible side effects of When a person has severe symptoms, a erythromycin include nausea, vomiting, and liquid or puréed diet may be prescribed. As abdominal cramps. liquids tend to empty more quickly from the stomach, some people may find a puréed diet

4 Gastroparesis Other medications. Other medications may close-up view of the tissues. Once implanted, be used to treat symptoms and problems the settings on the battery-operated device related to gastroparesis. For example, medi- can be adjusted to determine the settings cations known as antiemetics are used to that best control symptoms. help control nausea and vomiting. Jejunostomy Botulinum Toxin If medications and dietary changes don’t Botulinum toxin is a nerve blocking agent work, and the person is losing weight or also known as Botox. After passing an requires frequent hospitalization for dehy- endoscope into the stomach, a health care dration, a health care provider may rec- provider injects the Botox into the pylo- ommend surgically placing a rus, the opening from the stomach into the through the abdominal wall directly into a duodenum. Botox is supposed to help keep part of the small intestine called the jeju- the pylorus open for longer periods of time num. The surgical procedure is known as a and improve symptoms of gastroparesis. jejunostomy. The procedure is performed by Although some initial research trials showed a surgeon at a hospital or outpatient center. modest improvement in gastroparesis symp- Anesthesia is needed. The feeding tube toms and the rate of gastric emptying follow- bypasses the stomach and delivers a special ing the injections, other studies have failed to liquid food with nutrients directly into the show the same degree of effectiveness of the jejunum. The jejunostomy is used only when Botox injections.1 gastroparesis is extremely severe. Gastric Electrical Stimulation Parenteral Nutrition This treatment alternative may be effective When gastroparesis is so severe that dietary for some people whose nausea and vomit- measures and other treatments are not help- ing do not improve with dietary changes ing, a health care provider may recommend or medications. A gastric neurostimulator parenteral nutrition—an IV liquid food is a surgically implanted battery-operated mixture supplied through a special tube in device that sends mild electrical pulses to the the chest. The procedure is performed by a stomach muscles to help control nausea and surgeon at a hospital or outpatient center; vomiting. The procedure may be performed anesthesia is needed. The surgeon inserts at a hospital or outpatient center by a gas- a thin, flexible tube called a catheter into a troenterologist. General anesthesia may be chest vein, with the catheter opening outside required. The gastroenterologist makes sev- the skin. A bag containing liquid nutrients eral tiny incisions in the abdomen and inserts is attached to the catheter, and the nutrients a laparoscope—a thin tube with a tiny video are transported through the catheter into the camera attached. The camera sends a mag- chest vein and into the bloodstream. This nified image from inside the stomach to a approach is a less preferable alternative to video monitor, giving the gastroenterologist a a jejunostomy and is usually a temporary treatment to get through a difficult period of gastroparesis.

1Bai Y, Xu MJ, Yang X, et al. A systematic review on intrapyloric botulinum toxin injection for gastroparesis. Digestion. 2010;81(1):27–34. 5 Gastroparesis How is gastroparesis treated What are the problems of if a person has diabetes? gastroparesis? An elevated blood glucose level directly The problems of gastroparesis can include interferes with normal stomach emptying, so • severe dehydration due to persistent good blood glucose control in people with vomiting diabetes is important. However, gastropare- sis can make blood glucose control difficult. • gastroesophageal reflux disease When food that has been delayed in the (GERD), which is GER that occurs stomach finally enters the small intestine and more than twice a week for a few weeks; is absorbed, blood glucose levels rise. Gas- GERD can lead to — tric emptying is unpredictable with gastropa- irritation of the esophagus resis, causing a person’s blood glucose levels • bezoars, which can cause nausea, to be erratic and difficult to control. vomiting, obstruction, or interfere with The primary treatment goals for gastropare- absorption of some medications in pill sis related to diabetes are to improve gastric form emptying and regain control of blood glucose • difficulty managing blood glucose levels levels. In addition to the dietary changes and in people with diabetes treatments already described, a health care provider will likely adjust the person’s insulin • due to poor absorption of regimen. nutrients or a low calorie intake To better control blood glucose, people with • decreased quality of life, including work diabetes and gastroparesis may need to absences due to severe symptoms • take insulin more often or change the Points to Remember type of insulin they take • Gastroparesis, also called delayed gas- • take insulin after meals, instead of tric emptying, is a disorder that slows or before stops the movement of food from the • check blood glucose levels frequently stomach to the small intestine. after eating and administer insulin when • Gastroparesis can occur when the vagus necessary nerve is damaged by illness or injury A health care provider will give specific and the stomach muscles stop working instructions for taking insulin based on normally. Food then moves slowly from the individual’s needs and the severity of the stomach to the small intestine or gastroparesis. stops moving altogether. In some cases, the dietitian may suggest eat- • Most people diagnosed with gastropare- ing several liquid or puréed meals a day until sis have idiopathic gastroparesis, which gastroparesis symptoms improve and blood means a health care provider cannot glucose levels are more stable. identify the cause, even with medical tests.

6 Gastroparesis • Diabetes is the most common known Researchers are studying whether new cause of gastroparesis. People with dia- medications or surgery can improve gastric betes have high levels of blood glucose, emptying and reduce gastroparesis symp- also called blood sugar. Over time, high toms. Researchers are evaluating the safety blood glucose levels can damage the and effectiveness of nortriptyline for treat- vagus nerve. ment of gastroparesis. More information about one such study, funded under the • The most common symptoms of gastro- National Institutes of Health clinical trial paresis are nausea, a feeling of fullness number NCT00765895, can be found at after eating only a small amount of www.ClinicalTrials.gov. food, and vomiting undigested food— sometimes several hours after a meal. Participants in clinical trials can play a more Other common symptoms include gas- active role in their own health care, gain troesophageal reflux (GER), pain in the access to new research treatments before stomach area, abdominal bloating, and they are widely available, and help others lack of appetite. by contributing to medical research. For • Gastroparesis is diagnosed through a information about current studies, visit physical exam, medical history, blood www.ClinicalTrials.gov. tests, tests to rule out blockage or struc- tural problems in the gastrointestinal For More Information (GI) tract, and gastric emptying tests. American College of • Changing eating habits can sometimes 6400 Goldsboro Road, Suite 450 help control the severity of gastropare- Bethesda, MD 20817–5846 sis symptoms. A health care provider Phone: 301–263–9000 may suggest eating six small meals a day Email: [email protected] instead of three large ones. When a Internet: www.acg.gi.org person has severe symptoms, a liquid or American Diabetes Association puréed diet may be prescribed. 1701 North Beauregard Street • Treatment of gastroparesis may include Alexandria, VA 22311 medications, botulinum toxin, gastric Phone: 1–800–DIABETES electrical stimulation, jejunostomy, and (1–800–342–2383) parenteral nutrition. Email: [email protected] Internet: www.diabetes.org • For people with gastroparesis and dia- betes, a health care provider will likely International Foundation for Functional adjust the person’s insulin regimen. Gastrointestinal Disorders P.O. Box 170864 Hope through Research Milwaukee, WI 53217–8076 Phone: 1–888–964–2001 or 414–964–1799 The National Institute of Diabetes and Fax: 414–964–7176 Digestive and Kidney Diseases’ (NIDDK’s) Email: [email protected] Division of Digestive Diseases and Nutrition Internet: www.iffgd.org supports basic and clinical research into GI motility disorders, including gastroparesis.

7 Gastroparesis Acknowledgments National Digestive Diseases Publications produced by the Clearinghouse Information Clearinghouse are carefully reviewed by both NIDDK sci- 2 Information Way entists and outside experts. This publication Bethesda, MD 20892–3570 was reviewed by Linda A. Lee, M.D., Johns Phone: 1–800–891–5389 Hopkins University School of Medicine. TTY: 1–866–569–1162 Fax: 703–738–4929 Email: [email protected] You may also find additional information about this Internet: www.digestive.niddk.nih.gov topic by visiting MedlinePlus at www.medlineplus.gov. This publication may contain information about The National Digestive Diseases Information medications. When prepared, this publication Clearinghouse (NDDIC) is a service of the included the most current information available. For updates or for questions about any medications, National Institute of Diabetes and Digestive contact the U.S. Food and Drug Administration toll- and Kidney Diseases (NIDDK). The free at 1–888–INFO–FDA (1–888–463–6332) or visit NIDDK is part of the National Institutes of www.fda.gov. Consult your health care provider for more information. Health of the U.S. Department of Health and Human Services. Established in 1980, the Clearinghouse provides information about digestive diseases to people with The U.S. Government does not endorse or favor any digestive disorders and to their families, specific commercial product or company. Trade, proprietary, or company names appearing in this health care professionals, and the public. document are used only because they are considered The NDDIC answers inquiries, develops and necessary in the context of the information provided. distributes publications, and works closely If a product is not mentioned, the omission does not mean or imply that the product is unsatisfactory. with professional and patient organizations and Government agencies to coordinate resources about digestive diseases.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health

NIH Publication No. 12–4348 June 2012

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