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Gastric Emptying

Normal Stomach Emptying

The rate of normal gastric emptying ranges from 1 to 4.5 Calories per minute [1,2,3,4]. Nutrients (carbohydrates, fats and proteins) that empty from the stomach into the duodenum trigger negative feedback via the vagus nerve, which delays gastric emptying and thus adjusts the amount of food that can be released from the stomach to the absorptive capacity of the small intestine [5].

The upper part of the stomach (fundus) has a main role in emptying of solids and the lower one (antrum) in emptying of liquids [6].

Factors that STIMULATE Gastric Emptying

1. Food Factors

  • The volume of either solid or liquid foods [40,41,42].
  • Small particle size of solid foods [85,86].

2. Body Factors

  • Moderate exercise, like walking [43,44] or moderate cycling [45]
  • Hypoglycemia [48,49]
  • Functional dyspepsia [51,52,53]
  • Duodenal ulcer [54,55]
  • Alcoholic neuropathy [56]
  • Certain gastric (stomach) operations, such as partial surgical removal of the stomach (gastrectomy) [57] or vagotomy [58], or gastric bypass (bariatric surgery) [59] or gastrin-secreting pancreatic tumor causing multiple gastric ulcers (Zollinger-Ellison syndrome) [60]
  • Dysfunction of the autonomic nervous system [62]
  • Cyclic vomiting syndrome in adults [63,64]

3. Drugs

Drugs that stimulate gastric emptying: azithromycin, beta blockers [10], bethanecol, cisapride, clarithromycin, diazepam, domperidone, erythromycin, metoclopramide, naloxone (used to stimulate gastric emptying in critically ill individuals treated with opioids) [11,69], prostaglandine E2 [11], pyridostigmine (used in treatment of diabetic gastroparesis) [11,66].

H2 antagonists ranitidine, famotidine and nizatidine may or may not stimulate gastric emptying [70,71,72,73,74,167].

Stopping smoking can be associated with faster gastric emptying and thus with decreased satiety [47].

Symptoms of Rapid Gastric Emptying (Dumping Syndrome)

Early symptoms (10-30 minutes after meals) include bloating, nausea, vomiting, abdominal cramps and explosive diarrhea [60].

Late symptoms (1-3 hours after meals), which result from reactive hypoglycemia, include flushing, pale, clammy skin, dizziness upon standing (orthostatic hypotension), headache, impaired consciousness, increased heart rate, palpitations, hunger, tremor, fatigue and sleepiness [57,60,61,75].

Diet in Rapid Gastric Emptying

To avoid: easily digesting carbohydrates (sugars, baked goods from white bread, potatoes, white rice), milk and other dairy products; also avoid liquids within 30 minutes after meals [57,145].

To add into the diet: dietary fiber that slows gastric emptying: pectin, guar gum, glucomannan [76,96,145].

Factors That SLOW Gastric Emptying

1. Food Factors

  • Calorie content [81,82] and caloric density (calories per gram) of a meal [87,88].
    • Fatty foods, such as chocolate [83], delay gastric emptying, probably due to their high calorie content [84]; solid fats delay emptying more than liquid fats (oils, milk) [41]. A drug orlistat, which inhibits the enzyme lipase and thus slows the digestion of fats to fatty acids, increases gastric emptying rate in healthy individuals by about 50% [90] and increases blood glucose levels after liquid oil-glucose meals by 35% [91]. Long-chain fatty acids with 12 or more C atoms delay gastric emptying but short- and medium-chain fatty acids with less than 10 C atoms do not [92,93].
  • Viscosity of the food. Non-viscous fluids are emptied fastest, followed by viscous fluids, pureed foods, solid foods and finally, poorly chewed solid foods [16,41,94,95]. Certain viscous soluble fiber, such as guar gum (in doses >5 g) [76,96], pectin (in doses >10 g) [76], agar and glucomannan [100,101] can delay gastric emptying.
  • Alcohol. Beer and red wine can delay gastric emptying of solid foods [103] and a Japanese aperitif umeshu (14% abv) can delay emptying of liquids [104].
  • Calcium supplements slow gastric emptying [106].

2. Physiological Factors

  • Factors that stimulate sympathetic nerves, such as anxiety, fear, stress and pain [107,108]
  • Physical exercise above 70% intensity or in a hot environment (120 °F or 49° C) [109,110,111,112]
  • Pregnancy, probably due to high progesterone levels [16,17,107]

3. Health Conditions

ACUTE health conditions:

  • Fever [113]
  • Severe trauma [94] or burns [114]
  • Hyperglycemia in some, but not all, diabetics [115,116]
  • Brain tumor or trauma associated with elevated intracranial pressure [97]
  • Abdominal surgery can be followed by a temporary paralysis of the bowel (ileus) [119,120]. Resection of the vagus nerve (vagotomy) may temporarily reduce gastric emptying rate [16,121,122]. Anxiousness before surgery and immobilization after surgery may result in severely prolonged gastric emptying (>10 hours) [123].
  • Radiation therapy [105]

CHRONIC health conditions:

  • Diabetes type 1 and 2 [124]; NOTE: Some individuals with diabetes type 1 or 2 may have rapid gastric emptying due to dysfunction of the vagus nerve (autonomic neuropathy) or other causes [50]. Chronic hyperglycemia [16,48,125] and to a much lesser extent autonomic neuropathy [124,126] are associated with slow gastric emptying in individuals with poorly controlled diabetes. The severity of symptoms (nausea, bloating) does not necessary correlate with the extent of the gastric emptying delay [124,127]. The rate of gastric emptying does not change much in a course of diabetes in a certain individual [128].
  • Surgery: gastric surgery, gastric bypass, pancreatic resection [129], gallbladder removal, lung or heart transplantation [10,16,130].
  • Idiopathic gastroparesis is delayed gastric emptying without a known cause [16,65]. Individuals officially diagnosed with functional dyspepsia, irritable bowel syndrome (IBS) [16,131] or chronic fatigue syndrome (CFS) [132] can actually have delayed gastric emptying. Emptying of liquids is rarely delayed even in severe gastroparesis [133].
  • Depression [16,112]
  • Anorexia nervosa [144]
  • Gastric and duodenal disorders: duodenal adhesions, amyloidosis, atrophic gastritis with or without pernicious anemia or achlorhydria [134], bezoar, cancer, caustic injury, gastric reflux – GERD [135,136], peptic ulcer [54,137], polymyositis, polyps, scleroderma, systemic lupus erythematosus (SLE) [16,138,139]
  • Cancers: gastric, duodenal, pancreatic [16,139,140], paraneoplastic syndrome associated with small-cell lung carcinoma [16]
  • Celiac disease [142,143], Crohn’s disease [16]
  • Congenital disorders: cystic fibrosis [16], myotonic muscular dystrophy [16], hypertrophic pyloric stenosis [68], Turner’s syndrome [16]
  • Hormonal disorders: adrenal insufficiency (Addison’s disease), hyperthyroidism, hypothyroidism [16]
  • Liver cirrhosis, chronic pancreatitis [16,146]
  • Neurological disorders: brain tumor, multiple sclerosis, Parkinson’s disease, brain stem stroke, neuropathy (damage of the vagus nerve) [148], autonomic dysfunction [62]
  • Physical or sexual abuse in women [130,149]
  • Post-infectious gastroparesis, a common cause of “functional dyspepsia,” after infection with citomegalovirus (CMV), Epstein-Barr virus (EBV) (infectious mononucleosis), Herpes zoster (Varicella zoster), Rotavirus (stomach flu), Salmonella or Giardia (food poisoning), Borellia (Lyme disease), HIV/AIDS, Chagas disease (Trypanosoma cruzi), or after vaccination may last from several weeks to more than a year [13,16,117,118,150].
  • Chronic renal insufficiency [16]
  • Spinal cord injury (tetraplegics) [105]

4. Medications

  • Analgesics: acetaminophen
  • Anesthetics
  • Anti-asthmatics: adrenaline or epinephrine, dobutamine, salbutamol
  • Anti-cancer drugs: chemotherapy, interferon alpha
  • Anticholinergics: atropine, bentyl, levsin, oxybutinin
  • Antidepressants: tricyclic antideprtessants (amitriptyline, doxepin), SSRIs (fluoxetine, paxil)
  • Anti-diabetics: exenatide, liraglutide
  • Antiemetic ondansetron
  • Anti-epileptics: carbamazepine
  • Antihistamines: loratadine, diphenhydramine
  • Anti-malarics: chloroquine
  • Anti-parkinsonian drugs: L-dopa
  • Antipsihotics: lithium
  • Gastric acid-lowering drugs: antacids (aluminum hydroxide), H2 inhibitors (ranitidine), protein pump inhibitors (omeprazole), sucralfate (in individuals with duodenal ulcer) [55]
  • Hormones: calcitonin, glucagon, octreoide, oxytocin, progesterone
  • Intravenous nutrition
  • Marijuana, nicotine
  • Opioids: codeine, fentanyl, methadone, morphine, tramadol
  • Potassium supplements
  • Sedatives
  • Vaccination for tetanus, hepatitis
  • YGD (Yerba Mate leaves, Guarana seeds, Damiana leaves)
  • References: [4,16,77,108,151,152,153,154,155,156,157,158]

Symptoms of Slow Gastric Emptying

Symptoms of delay gastric emptying occur soon after eating and can include early satiety, heartburn, frequent burping, acid reflux, nausea, abdominal pain after eating, constipation, diarrhea, unintentional weight loss [16,152,179,148,180], depression and anxiety [181]. Intensity of symptoms is not necessary related with the extent of gastric delay [182].

Complications of slow gastric emptying may include hypoglycemia in individuals with insulin-dependent diabetes [13] and malnutrition caused by irregular eating due to poor appetite [148,183].

Measures to Improve Digestion in Delayed Gastric Emptying

  • Have smaller and more frequent meals, choose liquid rather than solid meals.
  • Avoid solid fats (oils may be well tolerated), soluble fiber (beans, oats, barley, dried fruits), large amounts of alcohol
  • Chew the food well.
  • Avoid smoking and unnecessary stress.
  • References: [10,16,150]

Medications to treat slow gastric emptying:

  • Erythromycin [10,174,175,184]; tolerance can develop with time
  • Metoclopramide [10,159,166,174,176,183] may not be very effective in reducing symptoms; it also has several side effects; it is intended for a short-term treatment [10].
  • Mitemcinal [27]
  • Domperidone has fewer side effects than metoclopramide [174,175,176,192] but is not approved by the U.S. Food and Drug Administration (FDA), though [183].
  • Bethanechol [10]
  • Mirtazapine and tricyclic antidepressants (in refractory cases) [10,176]
  • Botulinus toxin injections [10]
  • Gastric electric stimulation [10,182]
  • Gastrostomy, jejunostomy or gastric resection [10]
  • Botulinus toxin injected to pylorus (in diabetic gastroparesis) [141,182]
  • Azithromycin [133,141]

Drugs to relieve nausea in delayed gastric emptying:

  • Phenothiazines: prochlorperazine, trimethobenzamide, and promethazine [10]
  • Ondansetron and benzodiazepines can help relieve nausea in individuals on chemotherapy [10]
  • Antihistamines: diphenhydramine, dimenhydrinate and meclizine [10]

What May Not Affect Gastric Emptying

Foods:

  • Carbonated beverages probably do not significantly affect gastric emptying, but this can vary greatly among individuals [38,160,161].
  • The type of a macronutrient (carbohydrates, proteins or fats) [81,88]
  • Water (up to 1 liter) taken with solid meals does not significantly accelerate stomach emptying [162].
  • Alcohol digestifs (40% abv) may stimulate gastric emptying, but this may vary greatly among individuals [163].
  • Espresso coffee [163]
  • Ginger [164,165]
  • Vinegar [168,169,170]
  • Chewing gum [171]

Conditions:

  • The body position [51]
  • Age [89,107]
  • Obesity [177,178]

Emptying of LIQUIDS

The faster the emptying of liquids from the stomach, the faster their absorption in the small intestine. A certain individual empties liquids of the same type, calorie content, amount and temperature at about the same rate [30].

What stimulates the gastric emptying of liquids: the volume of the liquid [31,32].

What slows gastric emptying of liquids:

  • Solid foods [33]
  • Carbohydrate content as low as 2.5%, but usually only when higher than 7%, and especially when higher than 10%, can slow gastric emptying of liquids [34,35,78,79].
  • Glucose added to water slows gastric emptying more than galactose and this more than fructose [78].
  • Liquids that are much colder than the body temperature (98.6 °F or 37 °C) can slow stomach emptying [102].
  • Exercise at intensities greater than 60% can slow gastric emptying of water and carbohydrate solutions [80]. In trained marathon runners, running had no effect on the gastric emptying of solid meals [46].
  • Fiber added to liquid meals slows their emptying from the stomach [98].

Half-emptying time of 500 mL of different beverages in 2 studies [36,37]:

  • Water: 15-30 minutes
  • Fructose solution (10%): 60 minutes
  • Glucose solution (10%): 65-90 minutes
  • Beer (4% abv): 40 minutes
  • Red wine (10% abv): 75 minutes
  • 125 mL of whiskey (40 vol% alcohol) followed by 125 mL water: 25 minutes

Emptying of SOLIDS

Solid foods can empty from the stomach in 3-6 hours [39,172,173]. Solids empty from the stomach when they are ground to less than 2 mm size particles [4,39].

Gastrointestinal Hormones that Regulate Gastric Emptying

Gastrointestinal hormones that stimulate gastric emptying: amylin (a pancreatic hormone), gastric inhibitory polypeptide (GIP) [7], ghrelin [8,9], motilin [8] and its synthetic analog mitemcinal [27].

Gastrointestinal hormones that (may) slow gastric emptying: amylin (a hormone secreted from the pancreas) [22] and its synthetic analog pramlintide [23] cholecystokinin (CKK) [8,13,14], glucagon [10,11], glucagon-like peptide-1 (GLP-1) [4,8,20,21], leptin [25], pancreatic polypeptide [28], peptide YY (PYY) [8], secretin [29] and somatostatin [18,19].

Other hormones that may slow gastric emptying: calcitonin [10,11], dopamine [12,15], enkephalins (endogenous opioids) [24], melatonin (in pharmacological doses) [26], octreoide [10] and progesterone [16,17].

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