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Mistakes in... 2021
Mistakes in gastroparesis and how to avoid them
Asma Fikree
The term 'gastroparesis' was first coined by Kassander in 1958 to describe the fact
that barium did not leave the stomach of patients with diabetes for over 24 hours -
so-called 'gastroparesis diabeticorum'.1
Nowadays it refers to a delay in gastric
emptying that is associated with symptoms primarily of nausea and vomiting as
well as the absence of mechanical obstruction.
In 1958, 21 cases were described, but in 2019, 5 million US individuals were
diagnosed as having gastroparesis. This rapid increase in prevalence is likely to have
occurred because it has become much easier to measure gastric emptying and to attribute
symptoms to this without necessarily thinking through differentials. The incidence of
hospital admissions for patients labelled as having gastroparesis is rapidly rising,
increasing at a much faster rate than admissions for patients with nausea and vomiting,
gastro-oesophageal reflux disease, gastritis or gastric ulcers, which are all remaining
relatively static. Gastroparesis therefore represents a major healthcare burden.2
Gastroparesis can be idiopathic or is most frequently caused by diabetes
(type 1 more than type 2) or surgical procedures that can disrupt the vagus nerve
(e.g. Billroth gastrectomy, oesophagectomy, gastric bypass surgery and fundoplication).
In this article, I describe the mistakes most frequently made in patients who have a
suspected diagnosis of gastroparesis. I base my discussion on the available evidence as
well as clinical experience in the field.
Mistake 1 Diagnosing gastroparesis using
incomplete evidence
A diagnosis of gastroparesis requires three
features to be met - a delay in gastric emptying,
the absence of mechanical obstruction and typical
symptoms (figure 1). Typical symptoms include
nausea and regurgitation/vomiting, usually of
undigested food, within a few hours after a meal,
Diagnosing gastroparesis
✓
✓
✓
A delay in gastric emptying
The absence of mechanical obstruction
Typical symptoms
* Nausea and regurgitation/vomiting,
usually of undigested food, within
a few hours of eating
* Other dyspeptic symptoms (e.g. early
satiety, postprandial fullness,
epigastric bloating and epigastric
discomfort or pain
but can also include other dyspeptic symptoms
such as early satiety (feeling full very quickly after
a few mouthfuls), postprandial fullness (feeling
uncomfortably full after a meal, as if the food
cannot pass through the stomach), epigastric
bloating (which can be visible) and epigastric
discomfort or pain. A delay in gastric emptying
that is not accompanied by typical symptoms
should not be classified as gastroparesis and
should simply be referred to as 'delayed gastric
emptying'. If the predominant symptoms are more
those of dyspepsia but there is no nausea and
vomiting, the diagnosis is most likely to be
functional dyspepsia, which has a different
treatment algorithm (see mistake 2).
It is tempting to infer a diagnosis of delayed
Figure 1 | Features required to make a diagnosis of
gastroparesis.
gastric emptying after performing a gastroscopy
that shows food in the stomach after a 6-hour fast.
Although this would be a differential in a patient
who has symptoms of nausea and vomiting and
the right predisposing factors, such as diabetes,
it is crucial to remember to consider important
organic differentials, such as neoplasia, that can
cause a gastric-outlet obstruction. In patients who
have gastroparesis, there are usually no alarm
signs, with anaemia and weight loss being rare,
so finding either of these should act as a prompt
to look carefully for an underlying malignancy
using enteroscopy or cross-sectional imaging as
© UEG 2021 Fikree.
Cite this article as: Fikree A. Mistakes in gastroparesis and how to
avoid them. UEG Education 2021; 21: 18-22.
Asma Fikree is a consultant gastroenterologist at the Royal
18
London Hospital in London, UK, and an honorary senior lecturer
at Barts and the London School of Medicine and Dentistry, Queen
Mary University London, UK.
Image: A. Fikree. Illustration: J. Shadwell.
appropriate.3 In patients who have retained food
and fluid in their stomach after an adequate fast,
it is important to get a more complete view by
repeating the gastroscopy after a longer fast and
after they have stopped taking any drugs that may
contribute to delayed gastric emptying (e.g.
opiates). If obstructive causes have been excluded,
then delayed gastric emptying would need to
be confirmed using either breath testing or
scintigraphy tests.
It should be noted that the degree of gastric
emptying is dependent on the type of meal
consumed and that the pattern and rate of
emptying can vary considerably between
individuals. Based on a large multicentre study,
consensus guidelines have been developed to
define what constitutes delayed gastric
Time after
meal
1h
2h
3h
4h
Upper limit of gastric retention
values for a low-fat meal
90%
60%
30%
10%
Table 1 | Diagnosing delayed gastric emptying:
normal values for percentage retention of a low-fat
meal.
Correspondence: asma.fikree@nhs.net
Conflicts of interest: The author declare they have no conflicts of
interest in relation to this article.
Published online: May 20, 2021.
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