Mistakes in ... 2021 - 31

ueg education
Mistakes in... 2021
emptying.4 With a typical 255 kcal (2% fat/low
fat) meal, delayed gastric emptying is defined as
retention ≥60% at 2 hours and ≥10% at 4 hours.
Normal values for gastric emptying will change
if the meal is high fat, nutrient drink, or mixed
solid/liquid, so it is important that the
correct reference ranges are used (Table 1). It is
recommended that scintigraphy is performed
over 4 hours to ensure accuracy of the results.
With the pressures on healthcare systems,
however, it is common to perform shorter
studies (e.g. 90 minutes or 2 hours), but this can
be misleading and can cause an overdiagnosis of
gastroparesis.
Mistake 2 Not considering conditions than
mimic gastroparesis
There are several conditions, including several
functional gastrointestinal disorders, that
can have a similar clinical presentation to
gastroparesis and that are associated with delays
in gastric emptying (figure 2). These conditions
should therefore be considered and systematically
excluded to ensure management strategies are
adapted appropriately.
First is functional dyspepsia, which is the
closest mimic to gastroparesis. Functional
dyspepsia can be divided into epigastric pain
syndrome and postprandial distress syndrome.
Postprandial distress syndrome is characterised
by symptoms of early satiety, postprandial
fullness, epigastric bloating and epigastric
discomfort or pain, symptoms that are almost
identical to those of gastroparesis but with less
nausea and vomiting. About a third of patients
with functional dyspepsia will have mild to
moderate delays in gastric emptying. The
pathophysiology of functional dyspepsia is
mainly due to a combination of abnormal gastric
accommodation and visceral hypersensitivity.
In practice, the presence of regular nausea and
vomiting/regurgitation of undigested food would
point towards a diagnosis of gastroparesis.
The second condition is rumination syndrome,
which causes effortless regurgitation, mainly
postprandially. This is a behavioural phenomenon
caused by subconscious abdominal contractions
that cause the regurgitation of food back into the
oesophagus. It can be associated with dyspeptic
symptoms and in some patients, the rumination
behaviour develops as a response to the
dyspepsia because it often relieves this
sensation. Typical symptoms of rumination
syndrome include a cycle of regurgitation
followed by swallowing of the regurgitant
during or after meals, with this continuing until
the regurgitant becomes acidic and is then
expelled orally. Rumination syndrome can be
diagnosed using combined high-resolution
manometry-impedance monitoring, as this
can reveal a typical pattern of low-pressure
gastric straining followed by regurgitation
Gastroparesis mimics
* Functional Gastrointestinal Disorders
* Functional dyspepsia (postprandial
distress syndrome)
* Rumination syndrome
* Cyclical vomiting syndrome
* Cannabinoid hyperemesis syndrome
* Eating disorders
* Anorexia nervosa
* Bulimia nervosa
* Avoidant restrictive food intake
disorders (ARFID)
* Stress and anxiety
* Narcotic bowel syndrome
Figure 2 | Conditions than mimic gastroparesis.
(figure 3). Patients often complain that they
vomit after eating; however, if a thorough
history is taken, it can become clear that the
vomiting is effortless (i.e. regurgitation).
The treatment for this involves education and
deep-breathing exercises.
Third are cyclical vomiting and cannabinoid
hyperemesis syndromes, which cause episodic
attacks of vomiting that usually last for a few
days and can be associated with dehydration
and electrolyte imbalance. In between episodes,
patients are completely asymptomatic, which
is not the case for patients with gastroparesis.
Cyclical vomiting is very strongly associated
with a personal or family history of migraines
and cannabinoid hyperemesis syndrome
is associated with heavy cannabis intake and
the use of hot showers to relieve the nausea.
Both of these syndromes can be associated with
a delay in gastric emptying.
Eating disorders, such as anorexia nervosa
and bulimia nervosa, are the fourth conditions to
consider because a low body mass index is
associated with delays in gastric emptying and
disturbed gastric functioning. It is therefore
important to look for a history of eating
disorders because the treatment for
such disorders involves psychological therapy
and enforced nutrition, not, for example, the use
of prokinetics.
Fifth are stress and anxiety, which can
centrally induce nausea and vomiting. If the
anxiety is directed towards food, so-called
'avoidant restrictive food intake disorder',5
this condition might present more like
gastroparesis, with immediate postprandial
nausea and vomiting. Patients may complain
that they only have to see food or put it in their
mouth for vomiting to occur. This very early
response to food, before the food even reaches
the stomach, should point more towards
Impedance
tracing
2. Retrograde
movement
of liquid
6. Peristaltic
clearance
3. UOS open
Upper
oesphageal
sphincter
4. Swallow
Manometry
tracing
Patient
reports
vomiting
5. Perstalsis
1. Gastric
strain
Lower
oesphageal
sphincter
Figure 3 | Diagnosis of rumination by combined high-resolution manometry-impedance monitoring.
Rumination demonstrates a typical pattern of low-pressure gastric straining followed by regurgitation.
19

Mistakes in ... 2021

Table of Contents for the Digital Edition of Mistakes in ... 2021

Mistakes in ... 2021 - 1
Mistakes in ... 2021 - 2
Mistakes in ... 2021 - 3
Mistakes in ... 2021 - 4
Mistakes in ... 2021 - 5
Mistakes in ... 2021 - 6
Mistakes in ... 2021 - 7
Mistakes in ... 2021 - 8
Mistakes in ... 2021 - 9
Mistakes in ... 2021 - 10
Mistakes in ... 2021 - 11
Mistakes in ... 2021 - 12
Mistakes in ... 2021 - 13
Mistakes in ... 2021 - 14
Mistakes in ... 2021 - 15
Mistakes in ... 2021 - 16
Mistakes in ... 2021 - 17
Mistakes in ... 2021 - 18
Mistakes in ... 2021 - 19
Mistakes in ... 2021 - 20
Mistakes in ... 2021 - 21
Mistakes in ... 2021 - 22
Mistakes in ... 2021 - 23
Mistakes in ... 2021 - 24
Mistakes in ... 2021 - 25
Mistakes in ... 2021 - 26
Mistakes in ... 2021 - 27
Mistakes in ... 2021 - 28
Mistakes in ... 2021 - 29
Mistakes in ... 2021 - 30
Mistakes in ... 2021 - 31
Mistakes in ... 2021 - 32
Mistakes in ... 2021 - 33
Mistakes in ... 2021 - 34
Mistakes in ... 2021 - 35
Mistakes in ... 2021 - 36
Mistakes in ... 2021 - 37
Mistakes in ... 2021 - 38
Mistakes in ... 2021 - 39
Mistakes in ... 2021 - 40
Mistakes in ... 2021 - 41
Mistakes in ... 2021 - 42
Mistakes in ... 2021 - 43
Mistakes in ... 2021 - 44
Mistakes in ... 2021 - 45
Mistakes in ... 2021 - 46
Mistakes in ... 2021 - 47
Mistakes in ... 2021 - 48
Mistakes in ... 2021 - 49
Mistakes in ... 2021 - 50
Mistakes in ... 2021 - 51
https://www.nxtbookmedia.com