Do you have an underweight client struggling to eat more due to chronic nausea, vomiting, reflux, bloating or abdominal pain?  Do they feel full after consuming only a small amount of food or report constantly feeling full?  If yes to any of the above, you should have them tested for delayed gastric (stomach) emptying.

Delayed gastric emptying (also called gastroparesis), is when food stays in the stomach a lot longer than is considered “normal” and there is no blockage or mechanical obstruction that would explain this delay. When someone has gastroparesis, the usual strategies given to help someone gain weight (such as using oral nutrition supplements or consuming high fat, high protein and/or high calorie foods), are often ineffective and can actually make their symptoms worse.

Causes of gastroparesis (1, 2, 3, 4)

There are several factors that contribute to the development of gastroparesis.  Keep in mind that nerves are what coordinate the smooth muscle contraction-relaxation of the stomach.   Anything that interferes with the functioning of the nerves or muscles can therefore delay stomach emptying.

1) Having a brain injury or a spinal cord injury

If the brain injury or spinal cord injury have impaired the functioning of muscle fibres in the body and/or affected the vagus nerve, there is a good chance that gastric emptying will be negatively affected as well.

Initially after a traumatic brain injury, gastroparesis occurs in 45-50% of clients, although it will often (but not always) resolve on its own after ~2 weeks.  People with a spinal cord injury that is higher than the mid-thoracic spinal region, are likely to have delayed gastric emptying as well.

2) Diabetes

Gastroparesis is caused by diabetes in 38-57% of cases.   This is because chronically high blood glucose levels over 5+ years, can damage the nerves in the body (including the nerves of the stomach). For people with type 1 diabetes, 50% will develop gastroparesis while 30% of people with type 2 diabetes will develop it.

3) Medication

Medication-induced gastroparesis accounts for 12-20% of cases.  Opioids (e.g. for pain management), anticholinergic agents (e.g. for overactive bladder), calcium-channel blockers (e.g. amlodipine for high blood pressure) and glucagon-like peptide 1 agonists (e.g. liraglutide or semaglutide for diabetes or weight management) are the most common contributors to medication-induced gastroparesis.

4)  Idiopathic & other causes

There is no known cause for 11-50% of cases.  Gastric surgery and viral/bacterial infections are other possible explanations.

Diagnosing gastroparesis (1, 3)

If you suspect a client has gastroparesis, ask the GP to first refer them for an upper endoscopy (to rule out a mechanical obstruction).

If that comes back negative, then ask the GP to refer the client for a “gastric emptying study.”  During this procedure, clients will be asked to consume a radiolabelled meal (e.g. often egg whites, toast, jam and water).  The client will then be scanned several times in the 4 hours after consuming the food, to track how quickly the stomach empties and determine how much food remains in the stomach (compared to “normal” digestion).

Managing gastroparesis

Once gastroparesis is diagnosed, there are several options for managing this condition:

1) Medication (1, 5, 6)

• Step 1 – ask the GP to review and stop any medications which may be contributing to the gastroparesis.

• Step 2 – ask the GP or gastroenterologist to prescribe a prokinetic medication such as metoclopramide, erythromycin and/or prucalopride.  These medications try to speed up the rate at which food empties from the stomach.

• Step 3 – ask the GP to manage any residual symptoms (e.g. nausea) which haven’t yet resolved with Steps 1 & 2.

2) Dietary changes (1, 7, 8)

Clients with gastroparesis need to be referred to a dietitian because they are at high risk of malnutrition, nutrient deficiencies and dehydration.  Dietitians can then advise clients on how to change the type, texture and frequency of food eaten to help self-manage this condition without becoming malnourished.  Dietary changes alone are not usually sufficient and clients will also need to implement other management strategies from this list.

• Limit fat – fat delays stomach emptying, so clients with gastroparesis generally tolerate a low-fat diet much better (although this is very individual).  It may seem counterintuitive to promote low-fat foods to someone who is underweight, but low-fat foods consumed more often in the day (because they are digested faster) can lead to a higher calorie intake overall.

• Limit fibre – fibre can delay stomach emptying further, be hard to digest and/or increase gas production. Fibre can also bind together causing a phytobezoar (a mass of undigested fruit and vegetable fibre in the stomach or other parts of the digestive tract).  Apples, berries, coconut, figs, oranges, persimmons, Brussel sprouts, celery, green beans and potato peels are typically the worst offenders for creating phytobezoars and should be avoided by people with gastroparesis.

• Choose a liquid, mashed or blended diet – liquidised food or food that has a small particle size will digest faster than solid food.  Smoothies, low fat milk, pure fruit juice, soups, mashed potatoes and cereals tends to be better tolerated, as long as these foods are not spicy or acidic.

• Have 6-10 “mini-meals” per day – most clients with gastroparesis prefer to “graze” throughout the day and eat small amounts every 2-3 hours so that they don’t become overly full.

• Sit, stand or walk after eating – movement after eating helps speed stomach emptying.

• Manage blood glucose levels in people with diabetes – high blood glucose levels can slow gastric emptying and then further damage the nerves which control the stomach.

• Enteral (tube) feeding – if someone is at nutritional risk because they are unable to consume sufficient calories from their oral intake, then tube feeding should be considered. The feeding tube would need to be placed into the jejunum (small intestine) to bypass the dysfunctional stomach.

3) Gastric electrical stimulation (1)

If changes to medication and diet do not adequately manage symptoms, an electrode device can be surgically implanted into the stomach wall to stimulate contractions.  This is generally used when gastroparesis is idiopathic or due to diabetes.

4) Endoscopic procedures or surgery (1, 7)

Gastric peroral endoscopic myotomy (G-POEM) is a minimally invasive endoscopic procedure that cuts the muscles near the bottom of the stomach to allow food to move freely into the intestine.  Alternatively, gastric bypass may also be considered in clients with severe gastroparesis, if none of the other strategies above provide sufficient relief.

The symptoms of gastroparesis can be very generic and easy to attribute to other problems, thus making an accurate diagnosis difficult.  This condition can negatively affect someone’s quality of life and put them at huge nutritional risk, so it’s important that these symptoms are not ignored.

To refer a case management client for a comprehensive dietetic assessment and report, contact Specialist Nutrition Rehab at 0121 384 7087 or info@specialistnutritionrehab.co.uk.

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