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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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7 Responses to "Gastric Emptying"

  1. Linda Bryan says:

    Thank you for your website.

    You have neglected to include a category of slow stomach emptying patients: those with post-surgical gastroparesis (can be from bariatric surgeries, Nissen fundopliations, hiatal hernia repair, gall bladder surgery, and other surgeries). They are assumed to have sustained some sort of damage to the vagus nerve.

    Other categories of gastroparesis patients are diabetics, ideopathics (which you mention above and which may overlap with the “post-infectious” group you do mention, although no certain data is available), and patients who have sustained some kind of abuse to the digestive system by opiods or eating disorders. In gastroparesis patients, it is assumed that the usual peristaltic wave is not functioning properly. The gastric emptying problems are compounded by diarrhea, constipation, and GERD and some of the patients suffer from prolonged nausea and vomiting. Malnutrition can be a side-effect. Many gastroparesis patients suffer from quality of life issues as well as social and psychological stresses because the condition is not well understood, even by many health care professionals and because there are few treatments; careful food choices and symptom control are among them.

    Gastroparesis patients have begun a campaign to be noticed, recognized as having valid physical complaints, and respected. They are also attempting to increase the attention paid by researchers to gastroparesis. If your website can aid them by including more information on the debilitating nature of severe delayed gastric emptying, it would be very much appreciated.

    • Jan Modric says:

      Linda, if you think you can point out main practical problems people with post-surgical or other gastroparesis have, I may consider to research and write a separate article about it. This is primarily a website about nutrients, so this article was meant to show which factors can speed up or slow down nutrients absorption.

  2. Derrick Pohl says:

    In “Diet in Rapid Gastric Emptying”, it says to add “dietary fiber that slows gastric emptying: pectin, gaur gum, glucomannan.”

    This is confusing for the Late (1-3 hours after meals) version of Dumping Syndrome — do we want to slow gastric emptying? Or speed it up?

    I guess we’d want to do both — make gastric emptying happen sooner, without the 1-3 hour delay, but have it happen more slowly when it finally does begin. So should we add “dietary fiber that slows gastric emptying” for Late Dumping Syndrome, or shouldn’t we?

    • Jan Modric says:

      I understand early and late dumping syndrome as 2 phases , not 2 versions of the syndrome. In some people, symptoms appear in the early phase in others in the late phase and in some in both phases. In all cases, slowing, not speeding, gastric emptying makes sense.

      Symptoms of the early phase occur when food moves from the stomach into the small intestine. Symptoms of the late phase occur when glucose is absorbed and causes a quick rise and then fall of the blood glucose levels.

  3. Kerrie says:

    As I sit here after 30 hours of extreme pain and vomiting again, (I am hoping this round is over, I lost this one too), I have a better understanding of gastroparesis. There is not enough information out there. I was diagnosed five years ago. Have had problems since age 12. I am now 48. It has been a difficult and lonely life. I am rarely seen in a restaurant, hard to make plans with friends, family. They are used to mom/grandma getting sick. I have become the one who cannot be counted on to keep plans. This article is the first I have read detailing what those of us who suffer need to know.
    My years of experience with this beast have taught me what I can and cannot eat, as it can be different with everybody, but having a deeper understanding of why , brings hope.
    Love and light to my fellow sufferers.
    Thank you.

  4. Rosey says:

    OMGoodness, I have to read and reread and study this page a thousand times!!! I SOOO hope that you, Jan Modric, will see and respond to this! I know and get that this is not medical advice and for educational purposes only, AND I’m hoping you can help educate me further!? I have so many questions, but for now I’ve got 4 for you if you can, and are willing to, put your fine mind together with mine to try to help me understand all youve said here better and share your thoughts on these issues to help me to get a clearer picture, as you seem to me to have a better understanding of this than anyone I’ve EVER come across!!! And having lost about 20 years of having an “actual life” to, I now strongly suspect, this, all the while desperately searching for a clue, I have come across A TON! After SOOO many medical professionals and many thousands of dollars, and also hours spent researching it myself looking for some explanation for what’s been going on with me and FINALLY, at 2:00am today I find you here!!! Wow!!! THANK YOU!!! BEYOND WORDS, I THANK YOU!!! Okay, my questions…

    1. Do you think it is possible for a person to experience the Rapid Gastric Emptying problem like 95% of the times I eat (both the earlier symptoms, 10 to 30 minutes after the first bite of, what seems like, almost any food. In particular intense and extreme cramping and explosive diahrea and then also the later symptoms you describe, 1 to 3 hours later) and then about 13 years into that (so, about 6 to 7 years ago) then start to occasionally get the Slow Emptying symptoms – maybe 5% of the time (with seemingly unending nausea and vomiting over and over for days)? Please feel free to explain with as much detail as you’d like if you think this could be possible, and any thoughts you have on the subject will be GREATLY APPRECIATED!!!

    2. I have found that white wine helps what happens with me more than anything else! As far as I can understand what you have written here, I don’t think you’ve mentioned white wine (I apologize if that is covered here and I’m not yet registering it). It seems to help dramatically! Usually within minutes of consuming about the equivalent to a shot glass worth of it! My question is, could that make sense to you with what you understand regarding Rapid Gastric Emptying (possibly with intermittent Slow Gastric Emptying)? I ask because EVERY doctor I’ve seen says that alcohol of any kind is an absolute No No with any diahrea and that wine can ONLY exacerbate it! Only my current Primary Care Provider (of about 5 years now) has said that he believes me and allows me to use wine medicinally (in moderation and always taking several day breaks from it with no withdrawal symptoms – and he monitors my liver and kidneys regularly and so far no issues whatsoever). I feel I’ve lost the ear of every other medical proffesional when I tell them wine helps… because they feel that it’s simply NOT POSSIBLE!

    3. When you say Pectin, are you talking about what apples have in them? And if so, how would you think that I might go about getting that in me? Like, eat some apple before, or during, or after eating food? One particular, highly pure, Apple juice (not sure if I’m allowed to mention a brand here) is my absolute life-saver when I get the nausea and vomiting for days, problem! Would you think I would just always drink sips of that through the day and night? Again, any and all thoughts are beyond welcome!!!

    4. Now this may be interesting to you, and I’m wondering if you can think of how/whether this could relate to the timeline of Gastric Emptying… Right around the same time that I started occasionally having the Slow/delayed Emptying (nausea and vomiting) problem sometimes, I also experienced (for about a year) a terrifying symptom… which was that approx 50% of the times that I would eat, somewhere within 10 minutes to 3 hours of my first bite if food I would experience Descending Paralysis for 30 to 90 minutes. My face would begin to droop, then neck, and if I didn’t get somewhere to lay down within 2 to 4 minutes I would end up collapsed on the table or floor for up to 90 minutes, not able to speak or move in any way. I was literally paralyzed episodically once to three times per day – unless I did not eat at all, which I often would do, but eventually I was sworn off of that method by loved ones as you can imagine (I was about 20 pounds underweight, likely from mal-absorption from 13 years of daily diahrea). Every person who witnessed this would try to reassure me that I simply had fallen asleep… then I would tell them everything they had said while I was “asleep” in exact detail and one by one they would come to realize that I was NOT sleeping. My question is… does this make any sense to you within the Slow or Rapid Emptying issue? Oh, during these paralyzed periods, (during this approx 1 year long nightmare when the paralyzed episodes just stopped happening as mysteriously as they had begun happening) while I was in the paralyzed state, these were the only times when my tummy was not painful or moving, like my insides seemed paralyzed as well. In fact, my signal that I’d soon be able to move again was that my stomach would begin to churn… within a minute or so of that, I’d be able to move again with normal ease! I was monitored in every way possible by doctors when it first started happening, as im sure you can imagine, and during these episodes my blood pressure would drop 30 to 70 points during the onset, and my heart rate would slow dramatically as well. The closest thing we ever got to an explanation/diagnosis of those episodes was “some impossible form of Vasovagal Syncope somehow taking place in impossibly slow-motion” as the Doctor scratched his/her head, baffled and in disbelief of what they were witnessing. My question is, based on your understanding, do you think that this could somehow fit into the Slow or Rapid Gastric Emptying realm? Thank goodness those episodes stopped, but still, with this issue of constant diahreah day in and day out and occasional days of emdless vomiting make living a normal life just about impossible as I cannot ever be more than 30 seconds from a toilet… UNLESS I do NOT eat ANYTHING… and ANY information or help to understand this or be able to effect it would be heaven sent!!!

    Thank you SOOO much again for your fine work here and I will likely have every word memorized within a week! As a layperson I do also hope that I will be better able to understand it by then, or find soneone who can help me to digest the amazing information contained in your amazing page!!!

    • Jan Modric says:

      1. Yes, I believe rapid and slow gastric emptying could appear interchangeably. The possible underlying causes could include a damage of the vagus nerve or autonomous neuropathy (from long-term poorly controlled diabetes mellitus or other causes), psychological reasons, food intolerances or physical problems, like an ulcer.

      2. If you believe that white wine helps and you are fine with it, I see no problem here. Sometimes, there is no need to know exactly how and why things work, but only if they work or not. Moderate amounts of alcohol as such do not cause diarrhea.

      3. Pectin is found in apples, among other. I mentioned pectin only as an example of a nutrient that can slow down gastric emptying, not directly as an advice to start consuming it. Pectin is a soluble fiber, which, in certain amounts can cause bloating. Apples also contain a lot of fructose, which, in some people, can trigger bloating and diarrhea.

      4. I don’t know. It could be some sort of autonomic nervous system dysfunction, and this could be again neurological or psychological.

      To know that your gastrointestinal symptoms are from rapid/slow gastric emptying you would need to have exact tests that would firmly confirm/exclude the diagnosis. There are many other causes of such symptoms, which are most commonly related to certain foods, psychological reasons or combination of both.

      You may want to read about a low-FODMAP diet and see if that can help.

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