Critical Care Medicine-Gastrointestinal, Nutrition and Genitourinary Disorders>>>>>Stomach
Question 4#

A 55-year-old man with hypertension, anxiety, and type 1 diabetes mellitus recently adjusted his medication regimen and began taking clonidine. He presents now with abdominal pain and nausea. This has been associated with occasional episodes of emesis of gastric contents over the past few weeks. His weight is unchanged. His vital signs are within normal limits. On physical examination, his abdomen is distended with moderate tenderness in the epigastrium, but no rebound or guarding. His electrolytes are unremarkable and his finger stick glucose is 350 mg/dL. Upper endoscopy and CT scan show large amount of gastric contents with no evidence of mechanical obstruction.

In addition to reviewing his medication list, what is the BEST next step in caring for this patient? 

A. Nasogastric decompression
B. Dietary modification and optimization of glycemic control
C. PPI treatment
D. Percutaneous gastrostomy tube for venting
E. Surgical consultation for gastrojejunostomy

Correct Answer is B

Comment:

Correct Answer: B

Gastroparesis, or delayed gastric emptying, is the motility disorder in which food remains in the stomach for a prolonged period of time. This typically presents with postprandial fullness, nausea, vomiting, pain, and/or bloating. It may be due to a variety of factors. Medications that prolong gastric emptying include alpha-2-adrenergic agonists (such as clonidine, which this patient is taking), narcotics, calcium channel blockers, tricyclic antidepressants, and incretin-based diabetes medications. Diabetes mellitus is also a risk factor for gastroparesis, with type 1 diabetics at greater risk than type 2. Once mechanical obstruction has been ruled out, the first-line therapy in gastroparesis is dietary modification and optimization of glycemic control. Large meals and foods high in fat or fiber should be avoided. In this patient, there is no mechanical obstruction and there is no current complaint of emesis, making nasogastric decompression unnecessary. Similarly, there is no mention of ulcerative disease on his endoscopy and therefore no indication for proton pump inhibitors. Gastrostomy tube is very rarely indicated in gastroparesis, and certainly not in this patient with recent onset of mild symptoms who has not yet tried lifestyle or medical management. Gastrojejunostomy can be used to bypass a mechanical gastric outlet obstruction but will not improve the motility of the stomach. 

References:

  1. Choung RS, Locke GR, Schleck CD, Zinsmeister AR, Melton LJ, Talley NJ. Risk of gastroparesis in subjects with type 1 and 2 diabetes in the general population. Am J Gastroenterol. 2012;107(1):82-88.
  2. Camilleri M, Parkman HP, Shafi MA, Abell TL, Gerson L. Clinical guideline: management of gastroparesis. Am J Gastroenterol. 2013;108(1):18-38.