MKSAP Quiz: Episodic nausea, bloating, epigastric pain
A 45-year-old woman is evaluated for episodic nausea, bloating, and epigastric pain of 5 years' duration, with occasional vomiting in the past 3 months, as well as near-daily heartburn symptoms that have not responded to daily omeprazole. She has a 10-year history of type 2 diabetes mellitus treated with metformin and glyburide. After physical exam, laboratory tests, and upper endoscopy, what is the next appropriate step in management?
A 45-year-old woman is evaluated for episodic nausea, bloating, and epigastric pain of 5 years' duration. In the past 3 months, the nausea has been accompanied by occasional vomiting. She also reports near-daily heartburn symptoms that have not responded to daily omeprazole. She has a 10-year history of type 2 diabetes mellitus that is treated with metformin and glyburide.
On physical examination, vital signs are normal; BMI is 29. Abdominal examination shows diffuse tenderness to deep palpation with no guarding. Other findings are normal.
Laboratory studies show a blood hemoglobin A1c level of 7.5%. The basic metabolic panel is normal. A complete blood count and liver chemistry tests are normal.
Upper endoscopy shows a moderate amount of retained food in the stomach and patchy erythema of the gastric mucosa. Biopsies of the stomach are normal.
Which of the following is the most appropriate next step in management?
A. Gastric emptying scintigraphy
B. 24-Hour pH probe
C. Initiation of domperidone
D. Initiation of metoclopramide
MKSAP Answer and Critique
The correct answer is A. Gastric emptying scintigraphy. This content is available to MKSAP 18 subscribers as Question 65 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.
Gastric emptying scintigraphy is the most appropriate next step in management. The diagnosis of gastroparesis requires: (1) the presence of specific symptoms; (2) the absence of mechanical outlet obstruction; and (3) objective evidence of delay in gastric emptying into the duodenum. Commonly reported symptoms include early satiety, postprandial fullness, nausea, vomiting, upper abdominal pain, bloating, and weight loss, but these symptoms correlate poorly with the findings on objective gastric emptying tests. Various other upper gastrointestinal disorders can present with similar symptoms. Exclusion of other upper gastrointestinal disorders, objective documentation of delayed gastric emptying, and an attempt to identify the cause of the gastroparesis are essential before treatment. Retained food in the stomach during upper endoscopy is not objective evidence of delayed gastric emptying. The three tests to objectively demonstrate delayed gastric emptying are gastric scintigraphy, wireless motility capsule, and the gastric emptying breath test. If scintigraphy is pursued, the 4-hour study is preferred over 90- or 120-minute studies due to increased diagnostic accuracy.
A 24-hour pH probe may be considered when heartburn symptoms do not respond to a higher dose of acid suppression therapy, such as twice-daily proton pump inhibitor therapy or a proton pump inhibitor plus a histamine receptor antagonist. This patient's medical therapy for heartburn symptoms should be optimized before further testing is pursued, and this test will not explain the patient's predominant symptoms of nausea, bloating, and epigastric pain.
Both metoclopramide and domperidone are effective in the treatment of gastroparesis. Metoclopramide is the only FDA-approved agent for the treatment of gastroparesis. Domperidone can be used under a special program administered by the FDA. The side effects of metoclopramide include dystonia, Parkinson-type movements, and tardive dyskinesia. Domperidone can prolong the QT interval on electrocardiography, potentially leading to cardiac arrhythmia. Before initiating treatment for gastroparesis, it is necessary to confirm the diagnosis.
Key Point
- The diagnosis of gastroparesis requires the presence of specific symptoms, absence of mechanical outlet obstruction, and objective evidence of delay in gastric emptying into the duodenum.