August is gastroparesis awareness month. Since I’ve never written a piece about gastroparesis, I wanted to use the momentum of awareness month to start talking about it on the Zebra Pit. Clinically, I have no doubt about having gastroparesis (GP), but I haven’t had a gastric emptying study done yet. I don’t really know what to expect in regards to getting care from a gastroenterologist for GP, so this article will help me to understand the process and frame my own expectations as well as yours if you too suspect you may have it. My research covers what GP is, how it’s diagnosed and a few of the medical interventions available for treatment.
What Is Gastroparesis?
Gastroparesis is rare, incurable condition that affects the normal movement of muscles in the stomach, characterized by delayed gastric emptying. In milder cases, GP can also be referred to by some physicians as dyspepsia. Some people with gastroparesis experience few symptoms, while others are plagued by severe symptoms. Some researchers have proposed a classification system for GP, ranging from mild, or grade 1, to severe, or grade 3. No one is certain what exactly causes gastroparesis, but it is believed to be caused by damage to the nerve that controls the stomach’s muscles, the vagus nerve. In some cases, damage to the vagus nerve has been confirmed (Mayo Clinic).
Common GI features of GP:
- delayed gastric emptying
- gastric atony
- gastric dysmotility
- gastric stasis
- gastrointestinal autonomic neuropathy
- gastroparesis diabeticorum
- severe functional dyspepsia (NORD)
Gastroparesis can be caused by a variety of factors, such as neuropathy, post-surgical complications, medications that cause delayed gastric emptying such as opioids, viral gastroenteritis, nervous system disorders (e.g., Parkinson’s), collagen disorders (e.g., EDS/HSD), connective tissue diseases (e.g., RA, lupus), metabolic disorders (e.g., diabetes and hypothyroidism), anorexia nervosa and bulimia, chronic liver or renal failure, and chronic pancreatitis. Gastroparesis may also be induced by medications, or associated with total parenteral nutrition or related to bone marrow and other organ transplants. Additional causes include paraneoplastic syndrome, mitochondrial disorders, visceral neuropathies, (e.g., Guillain-Barre syndrome) and visceral myopathies (e.g., systemic scleroderma) (NORD).
Reports from one tertiary referral center found that out of their 146 patients with gastroparesis: 36% were idiopathic (unknown causes), 29% were diabetic, 13% were post-surgical, 7.5% had Parkinson’s disease and 4.8% had collagen diseases (NORD).
Diagnosis of Gastroparesis
A diagnosis of gastroparesis is made based upon a thorough clinical evaluation, a detailed patient history, and a variety of specialized tests. Tests may first be performed to rule out other causes of delayed gastric emptying such as obstruction of the gastrointestinal tract. Additional tests are then performed to confirm a diagnosis of gastroparesis.
An upper endoscopic procedure could lead to a serendipitous diagnosis of gastroparesis through the discovery of identifiable food within the stomach after the pre-procedure overnight fast. This is usually a chance discovery of the disorder, however and not the first or most likely way to discover GP.
The radionuclide (scintigraphy) solid-phase gastric emptying test (GET) is the gold standard for diagnosing gastroparesis. The GET, which is a non-invasive test, is widely available and accessible. The test involves eating food that contains a small amount of radioactive material. The progress of this material is then tracked on scans. Many other methods are now being employed to track gastric emptying times; for instance a gastric breath test (not in common use in North America) and a new encapsulated recording device, called SmartPill measures gastric pH, GI luminal pressures, and determines gastric and intestinal transit time.
Other diagnostic tests for GP can include electrogastrography (EGG). The EGG can serve as a screening tool and is complementary to the gastric emptying test. The EGG is capable of detecting specific gastric electrical rhythm abnormalities and indirectly gives an indication of the integrity of the stomach’s Interstitial cell of Cajal, which are involved in the generation and propagation of electrical rhythmic activity. This test is generally done using a non-invasive method with cutaneous (skin) leads though it can also be done during endoscopy (NORD).
Conventional Treatment of Gastroparesis
In some cases, gastroparesis can be temporary. In the case of medicine induced gastroparesis, GP due to viral gastroenteritis and in some other cases, after treatment of 1-2 years, motility may return to normal, but this is rare and gastroparesis is considered incurable. It is possible to improve outcomes with treatment. The following is the treatment plan laid out by NORD:
In the case of grade 1 gastroparesis, symptoms can come and go and can often be managed through dietary modification and avoidance of medications that could exacerbate the condition. Grade 2, or compensated gastroparesis, is characterized by moderately severe symptoms. Individuals with Grade 2 gastroparesis are treated with medications that stimulate gastric emptying and medications that reduce vomiting; such individuals require hospitalization only infrequently. Grade 3, or gastric failure, is characterized by individuals who do not respond to medications used to treat gastroparesis. These individuals cannot maintain proper nutrition or hydration. Required therapies may include intravenous fluids, medications and nutrition, or surgery. Individuals with Grade 3 gastroparesis often require hospitalization.
Non-pharmacological interventions include: liquid vitamin supplements (including optimal levels of vitamin D), discontinuation of smoking and alcohol use, learning techniques of deep relaxation, the use of acupuncture or acupoint stimulation, and reviewing all medications and supplements with a pharmacist to insure current regimen is not contributing to delayed gastric emptying. Other non-pharmacological therapies for GP include autonomic retraining; often related to autogenic feedback training developed by NASA for space motion sickness, autonomic retraining has shown promise in selected patients.
Dietary changes include eating five to six small meals each day and avoiding high-insoluble fiber and high-fat foods, both of which can slow down stomach emptying. Lactose intolerance is common in gastroparesis, so avoidance of dairy is helpful, but fermented milk (yogurt) is fine. Some individuals do better with liquid or pureed foods while avoiding difficult-to-digest solid foods. Liquid nutritional supplements are also an excellent source of additional calories and proteins to make up for nutritional deficiencies resulting from a poor appetite.
Medications that stimulate gastric emptying are called prokinetics and are the primary treatment for gastroparesis. First-line medical treatment begins with the dopamine blockers. Of the two drugs, metoclopromide (Reglan) and domperidone (Motilitum), domperidone has a much better safety profile. Metoclopromide has serious neurological side effects, including irreversible tardive dyskinesia. Domperidone is now available in the United States through the FDA’s Investigational New Drug protocol. Next are the motilin agonists, such as erythromycin. Unfortunately, motilin agonists have a number of potential drug interactions and lose effectiveness over time. Cholinergic agonists, either direct-acting or via 5HT receptors, such as bethanecol (Urecholine) and cisapride (Propulsid), have been limited by the side-effect profile (especially, in the case of cisapride, for possible drug interactions) or are not used widely.
The most common symptom of gastroparesis is nausea and it can be enormously challenging to control. Often, medications used to reduce nausea and vomiting “antiemetics” are used in combinations and in conjunction with prokinetics. Common antiemetics used are prochlorperazine (Compazine), promethazine (Phenergan), and ondansetron (Zofran).
Abdominal pain is best managed by a pain specialty clinic where a selection of analgesics with the least impact on slowing the GI tract can be made.
Keeping a good bowel routine and avoiding constipation helps in the management of upper digestive symptoms of gastroparesis (NORD).
While these treatments are sometimes helpful for people with gastroparesis, at least for a period of time, most are not meant to be long term permanent solutions. There are many things one can do to improve symptoms using a naturopathic approach, which I will be addressing in a series I have written for the Unchargeables. The first article in the series, which discusses essential changes in medication and diet, can be found here; Natural Treatments for Gastraparesis. The second, forthcoming article, discusses the many natural substances you can use to treat the many unpleasant symptoms that are part of having GP.
Difficulties with Diagnosis
A doctor education presentation I found during my research stated that gastroparesis is over-diagnosed. I couldn’t help but roll my eyes at this ridiculous statement. I don’t believe it for a second. I’ve had a terrible time getting gastroenterologists to take my complaints seriously, and yet if they had, I would already have had tests for SIBO and gastroparesis over a decade ago. I have had neither, despite seeing no less than 5 GI’s in the last 20 years. Every single one has chosen to instead blame my problems on IBS, rather than run these simple tests.
And I’m not an unusual case with hard to decipher symptoms. I can no longer process most carbohydrates. I can no longer eat fatty meats. Before I modified my diet, medications and went on supplements that help, I dealt with constant stomach pain, nausea, GERD, frequent vomiting of undigested food, and often couldn’t eat more than a couple of bites before my stomach simply wouldn’t take anymore. I would be terribly bloated and miserable pretty much all the time. If not for the ways I’ve found to treat myself, I would definitely be beating down the doors of every GI in town until someone finally listened to me. As it is, I still suffer at least once a week, but usually more like 2-3 times a week with symptoms ranging from mild to severe.
I remember being frustrated by my last GI repeatedly asking me if I was diabetic. I had no idea why she kept asking and I was mildly offended that she couldn’t seem to remember or bother to refer to my chart. I have many diagnoses, but diabetes is not on the list. After she released me without having helped me (she actually made things worse then sent me on my way like I was graduating), I discovered gastroparesis through my own research. Now I’ve put it all together and I’m quite she was under the impression that she should only test me for GP if I was a diabetic, completely counting out the remaining 71% of GP patients, including myself. In my experience, like all rare disease in this country, poor doctor education appears to be preventing proper diagnosis of gastroparesis. For this reason, when seeking diagnosis it is paramount to have your symptoms well documented and have a clear picture of what procedures and tests should be done beforehand. Unfortunately, I could only find one journal article to back up this belief and unsurprisingly, it was in relation to the underdiagnosis of gastroparesis in, wait for it, diabetes types 1 and 2.
I’m sure this is complicated by the lack of standards in what constitutes GP. While some doctors believe in stage 1 or mild gastroparesis as a diagnosis, others refuse to use the label until patients are severe, instead using the functional dyspepsia diagnosis (NORD). Issues like these only contribute to the confusion surrounding gastroparesis.
Some Final Thoughts and Next Steps
While a select set of patients do seem to recover from gastroparesis, there is no cure: However, there are many ways to manage this syndrome and make people with GP quite a bit more comfortable. When it’s necessary, one should rely on conventional methods of addressing the symptoms of GP, however there are many ways to address these symptoms using natural medicines, diet and other changes in habit and medications that often yield excellent results.
For more information, take a look at the series recently published by the Unchargeables, “Natural Treatments for Gastroparesis.”
If you’re a person with gastroparesis, what are some of the things that have brought you the most relief? Be sure to let us know in the comments!