CONTENTS
- Basics
- Clinical presentation
- Epidemiology
- Causes
- Differential diagnosis
- Evaluation
- Diagnostic criteria
- Treatment
- Podcast
- Questions & discussion
- Pitfalls
This chapter explores acute gastroparesis in the context of critical illness. This often occurs due to a variety of physiological stressors, with subsequent resolution over time. Gastroparesis in the ICU is related to, but not identical to, gastroparesis encountered in an outpatient context.
Symptoms may vary depending on the clinical context (e.g., intubation), including:
- Nausea, vomiting.
- Early satiety.
- Abdominal pain.
- Inability to tolerate tube feeding (e.g., vomiting with high residual volumes).
- Gastroparesis affects ~2-3% of the general population. (33336872)
- Among ICU patients, gastroparesis is extremely common, with a prevalence of ~40% (depending on illness severity). (33336872)
- Gastroparesis may occur as an isolated entity, or it may be associated with dysmotility of the entire gastrointestinal tract. (33336872)
infection
- Sepsis may cause gastroparesis.
- Idiopathic gastroparesis often follows a viral or bacterial illness. (33336872)
medications
- Anticholinergic agents, e.g.:
- Diphenhydramine.
- Tricyclic antidepressants.
- Atropine, glycopyrrolate.
- Hyoscyamine, scopolamine.
- Beta-adrenergic agonists.
- Calcium channel blockers.
- Levodopa.
- Opioids.
- Octreotide.
- Hyperosmolar feeding tube formulations.
- Glucagon-like peptide I agonists.
metabolic abnormalities
- Adrenal insufficiency.
- Hyperglycemia.
- Electrolyte abnormalities (e.g., hypokalemia, hypomagnesemia). (33336872)
- Hypoparathyroidism or hyperparathyroidism.
- Hypothyroidism or hyperthyroidism.
neurological disorders
- Multiple sclerosis.
- Parkinson's disease.
- Stroke.
- Elevated intracranial pressure.
- Autonomic neuropathy, e.g.:
- Diabetic neuropathy.
- Collagen vascular disease.
- Paraneoplastic syndrome.
surgical / anatomic
- Esophagectomy, anti-reflux procedures, gastric surgery, or bariatric procedures. (34816707)
- Especially procedures that incur damage to the vagus nerve.
- Mesenteric ischemia.
- Chest or abdominal surgery with injury of the vagus nerve.
- Gastric outlet obstruction (GOO).
- Ileus.
- Small bowel obstruction.
A variety of tests may be utilized for ambulatory patients including advanced imaging (CT or MRI) to rule out obstruction, upper endoscopy, and scintigraphic gastric emptying studies. These are usually not used in the ICU setting.
GRV (gastric residual volume)
- Gastric residual volumes measured during tube feeding may be used to quantify the residual fluid in the stomach.
- Routine measurement of residual volumes in all patients does not appear to be beneficial (in terms of a reduction in ventilator-associated pneumonia). (23321763)
- Isolated elevation of gastric residual volumes without clinical signs of feeding intolerance (e.g., distension, nausea, or vomiting) doesn't require intervention. (28828195)
- If there is a clinical suspicion for gastroparesis (e.g., due to distension or vomiting), then gastric residual volume may be useful:
- Gastric residual volumes <250 ml argue strongly against gastroparesis.
- Gastric residual volume in the 250-500 ml range is nonspecific. Different studies vary in what the upper limit of a “normal” gastric residual volume is (with values ranging from 150 ml to 500 ml!). (28828195)
- Gastric residual volumes >500 ml may raise more concern for impaired gastric motility and generally requires temporary cessation of feeding. (33336872) However, this isn't specific to gastroparesis (it may also occur with small intestinal ileus or mechanical obstruction).
abdominal radiograph
- Gastric distension supports the diagnosis of gastroparesis..
- Its primary role of imaging is to exclude alternative diagnoses:
- Ileus.
- Mechanical small bowel obstruction.
- Acute gastric dilation: massively enlarged stomach that is life-threatening, with risk of gastric ischemia or perforation. (36227004)
There is no clear diagnostic criteria for gastroparesis in the context of acute illness. (34816707) The following criteria might provide a general guide:
- [1] Some objective evidence of gastric dilation, such as:
- Elevated gastric residual volume (especially >500 ml).
- Gastric dilation seen on radiologic studies (this may be pivotal among patients with small-bore feeding tubes that don't allow for measurement of a gastric residual volume).
- [2] Clinical manifestations, such as:
- Nausea, vomiting.
- Abdominal distension, pain.
- Feeding intolerance.
- [3] Exclusion of alternative diagnoses (investigation should include at least an abdominal radiograph).
#1) conservative interventions
post-pyloric feeding tube
- A post-pyloric small-bore feeding tube may provide a definitive solution for weeks.
- This might be an optimal bridge until gastric function resolves (as it often does with resolution of the underlying illness).
- If feasible, this has the advantage that it avoids medication side-effects.
- Careful maintenance is essential to avoid clogging these small-bore tubes.
removal of inciting causes
- Avoid problematic medications (listed above).
- Glycemic control (gastroparesis may be promoted by glucose levels above ~270 mg/dL). (33336872)
tube feeding formulation
- Intuitively it might seem that concentrated, smaller-volume tube feeding would be helpful. However, this may not be the case. Concentrated tube feeds tend to be hyperosmolar and high in fat – both of which slow gastric emptying.
- The TARGET trial found that patients receiving more energy-dense feeds (1.5 kCal/ml) experienced greater gastric residuals and more vomiting. However, patients receiving denser feeds also received more calories, which could factor into this as well. (30346225)
#2) medical therapies
basic principles of medical therapy
- Medical treatment consists of erythromycin/azithromycin with or without metoclopramide.
- Erythromycin is generally regarded as front-line therapy. However, erythromycin may functionally synergize with metoclopramide so combination therapy for persistent gastroparesis is reasonable.
- It's important to recognize that all of these therapies work on the stomach and proximal duodenum, so they will fail in patients who also have a paralytic ileus.
- Once feeding tolerance has been established for 24 hours, consider holding promotility medications. (34816707)
erythromycin
- Erythromycin stimulates motilin receptors in the foregut, promoting gastric emptying. ESPEN guidelines recommend erythromycin as the front-line promotility agent in the ICU. (30348463)
- Tachyphylaxis: The main drawback of erythromycin is that, over time, its use leads to tachyphylaxis (diminishing efficacy) due to down-regulation of motilin receptors. Thus, erythromycin often becomes ineffective over roughly three days.
- The dose is 250 mg IV three times daily. Gradual infusion over ~20 minutes may reduce adverse outcomes. (30294835, 34816707)
- Contraindications:
- QT prolongation or history of Torsade de Pointes.
- Acute hepatic injury.
- Myasthenia gravis.
- Side-effects may include hypotension, abdominal pain, nausea, vomiting, and diarrhea. (30855322)
azithromycin
- 250-500 mg IV may be utilized once to three times daily. (36227004, 33336872)
- Azithromycin may be useful in situations where erythromycin is contraindicated. Of note, azithromycin has a more favorable side-effect profile (e.g., no significant effect on QTc intervals).
- (Discussion of azithromycin here: 💉)
metoclopramide
- Metoclopramide may be used in combination with erythromycin to increase efficacy (potentially the most effective strategy). (29720852) Combination therapy may also reduce the likelihood of tachyphylaxis. (33336872)
- (Discussion of metoclopramide here: 📖)
#3) other potential therapies
gastrojejunostomy tube
- This is essentially a durable, percutaneous post-pyloric feeding tube. It may provide more durable, long-term nutrition. In the uncommon event that total parenteral nutrition (below) might be considered, use of a gastrojejunostomy tube is often preferable.
- Interventional radiology may place a venting gastrojejunostomy tube combination:
- One tube enters the stomach and transverses into the duodenum – this is used for feeding.
- Another lumen remains in the stomach and may be used to “vent” the stomach.
total parenteral nutrition (TPN)
- This is the modality of last resort, which should be used only if all of the above treatments are impossible.
- Total parenteral nutrition is a highly undesirable treatment for isolated gastroparesis. If the remainder of the bowel is functional (i.e., small intestine and colon), then it is often preferable to obtain percutaneous or surgical access to the small bowel and provide enteral feeds (e.g., gastrojejunostomy tube above).
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- Routine measurement of the gastric residual volume should be avoided. This may lead to over-diagnosis and over-treatment of clinically asymptomatic gastric dysfunction.
- Over-utilization of total parenteral nutrition in patients with challenging gastric motility should be avoided.
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References
- 23321763 Reignier J, Mercier E, Le Gouge A, et al. Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA. 2013;309(3):249-256. doi:10.1001/jama.2012.196377 [PubMed]
- 28818187 Vilz TO, Stoffels B, Strassburg C, Schild HH, Kalff JC. Ileus in Adults. Dtsch Arztebl Int. 2017;114(29-30):508-518. doi:10.3238/arztebl.2017.0508 [PubMed]
- 28828195 Vazquez-Sandoval A, Ghamande S, Surani S. Critically ill patients and gut motility: Are we addressing it?. World J Gastrointest Pharmacol Ther. 2017;8(3):174-179. doi:10.4292/wjgpt.v8.i3.174 [PubMed]
- 29720852 Ladopoulos T, Giannaki M, Alexopoulou C, Proklou A, Pediaditis E, Kondili E. Gastrointestinal dysmotility in critically ill patients. Ann Gastroenterol. 2018;31(3):273-281. doi:10.20524/aog.2018.0250 [PubMed]
- 30294835 Deane AM, Chapman MJ, Reintam Blaser A, McClave SA, Emmanuel A. Pathophysiology and Treatment of Gastrointestinal Motility Disorders in the Acutely Ill. Nutr Clin Pract. 2019;34(1):23-36. doi:10.1002/ncp.10199 [PubMed]
- 30346225 TARGET Investigators, for the ANZICS Clinical Trials Group, Chapman M, Peake SL, et al. Energy-Dense versus Routine Enteral Nutrition in the Critically Ill. N Engl J Med. 2018;379(19):1823-1834. doi:10.1056/NEJMoa1811687 [PubMed]
- 30855322 Plummer MP, Reintam Blaser A, Deane AM. Gut dysmotility in the ICU: diagnosis and therapeutic options. Curr Opin Crit Care. 2019;25(2):138-144. doi:10.1097/MCC.0000000000000581 [PubMed]
- 33336872 Rangan V, Ukleja A. Gastroparesis in the Hospital Setting. Nutr Clin Pract. 2021 Feb;36(1):50-66. doi: 10.1002/ncp.10611 [PubMed]
- 33354038 Govil D, Pal D. Gastrointestinal Motility Disorders in Critically Ill. Indian J Crit Care Med. 2020 Sep;24(Suppl 4):S179-S182. doi: 10.5005/jp-journals-10071-23614 [PubMed]
- 34816707 Stojek M, Jasiński T. Gastroparesis in the intensive care unit. Anaesthesiol Intensive Ther. 2021;53(5):450-455. doi: 10.5114/ait.2021.110959 [PubMed]
- 36227004 Salamone S, Liu R, Staller K. Gastrointestinal Dysmotility in Critically Ill Patients: Bridging the Gap Between Evidence and Common Misconceptions. J Clin Gastroenterol. 2023 May-Jun 01;57(5):440-450. doi: 10.1097/MCG.0000000000001772 [PubMed]