Jane from Houston sent us this question: “I have been taking PPI’s since July, omeprazole (20mg 2x/day), then I was switched to Carafate, then come August 21, I was prescribed pantoprazole (40mg 2x/day) AND famotidine (40mg before bed). I had an upper endoscopy done and was told I had gastritis. I’ve tried to express to my medical team that, even on the medications, I was experiencing burning sensations, abdominal pain, and heartburn, but my concerns were dismissed, and they just ordered a gastric emptying test. I’ve made the decision to wean myself off pantoprazole, so I started taking only one a day since October 03. October 13, I did the gastric emptying test. Now, I was told I have gastroparesis—and my stomach empties “a little” slower than normal… could I really have gastroparesis? I am not experiencing sudden fullness, vomiting, or nausea. Thank you.”
Gastroparesis or delayed gastric emptying is a rare disease that affects less than 4% of the population in Houston. Stomach in gastroparesis patients does not empty food into the intestine. As a result, patients with gastroparesis often complain of postprandial fullness, bloating, nausea and vomiting. Abdominal pain in the epigastric area may be present throughout the day and exacerbated by food intake. Typically, patients report early satiety and inability to finish a regular size meal. A positive gastric emptying study is diagnostic of gastroparesis. However, symptom severity does not always correlate with gastric emptying rate.
Several gastroparesis patients present with heartburn in addition to epigastric pain and bloating. Early and mild gastroparesis cases are not typically associated with nausea and vomiting. Subtle findings on upper endoscopy include gastritis from bile and food stasis. Hiatal hernia and distal esophagitis that is classic acid reflux signs are typically absent or barely present in gastroparesis cases.
Proper workup and diagnosis are crucial to differentiate GERD from gastroparesis. We don’t recommend blind treatment with PPIs before diagnosis. We also prefer to perform a gastric emptying study off PPIs since PPIs may delay gastric emptying. Finally, ambulatory pH testing may further help in differentiating GERD from gastroparesis.
Nissen fundoplication, the gold standard treatment for acid reflux, promotes gastric emptying and may help alleviate mild cases of gastroparesis. I offer hiatal hernia repair and Nissen fundoplication only for patients with severe acid reflux and mild gastroparesis. For severe acid reflux and moderate to severe gastroparesis cases, I perform a Nissen fundoplication with hiatal hernia repair and I add a partial longitudinal gastrectomy along the greater curvature. I have had great success with this approach.
For medically refractory gastroparesis patients with no acid reflux, I offer an antrum preserving longitudinal gastrectomy without hiatal hernia repair. Our success rate using this approach has been very high. I currently recommend a partial gastrectomy as opposed to gastric bypass or pyloromyotomy for all cases of severe gastroparesis.