Differentials
Acute pancreatitis
SIGNS / SYMPTOMS
Sudden onset of abdominal pain radiating to the back, epigastric tenderness, fever, and tachycardia.
Nausea, vomiting, history of cholelithiasis, and excess alcohol intake are often present.
INVESTIGATIONS
Serum amylase and/or lipase: elevated.
Arterial blood gas: may show hypoxaemia and acid-base disturbances.
Abdominal plain x-ray: may show a sentinel loop (isolated dilation of a segment of gut) adjacent to the pancreas, gas distending the right colon that abruptly stops in the mid or left transverse colon (cut-off sign), or calcifications.
Cyclic vomiting syndrome
Functional dyspepsia
SIGNS / SYMPTOMS
Common clinical condition with chronic symptoms of postprandial nausea, vomiting, fullness, epigastric pain, and bloating.[72] Symptoms are very similar to those seen in gastroparesis and it is difficult to distinguish these entities based on symptoms alone.
INVESTIGATIONS
Gastric emptying scintigraphy: often normal.[73]
Gastric outlet obstruction
SIGNS / SYMPTOMS
Mechanical obstruction in the distal stomach caused by a variety of conditions including pyloric stenosis and pancreatic cancer.
Symptoms of gastric outlet obstruction are very similar to gastroparesis.
INVESTIGATIONS
Gastric emptying scintigraphy: typically delayed.
Upper gastrointestinal endoscopy or imaging studies such as upper gastrointestinal series or CT scan of the abdomen: evidence of mechanical obstruction in the distal oesophagus.
Rumination syndrome
SIGNS / SYMPTOMS
Regurgitation of recently ingested food into the mouth.[74][75] Food is regurgitated within minutes of eating in rumination, as opposed to a slightly longer time phase between ingestion of food and vomiting in gastroparesis.
Nausea is typically absent in rumination.
INVESTIGATIONS
Gastric emptying scintigraphy: typically normal.[74]
Irritable bowel syndrome (IBS)
SIGNS / SYMPTOMS
Chronic condition characterised by abdominal discomfort, bloating, and altered bowel movements (either constipation or diarrhoea, or both).
Nausea and vomiting are atypical symptoms for patients with IBS. Co-existing gastroparesis should be ruled out in patients with IBS in whom nausea and vomiting are significant symptoms.
INVESTIGATIONS
Upper and lower gastrointestinal endoscopy, and abdominal imaging studies: unremarkable.
Crohn's disease
SIGNS / SYMPTOMS
Altered bowel movements (usually diarrhoea) and haematochezia.
Small bowel obstruction should be ruled out in patients with fibrostenotic Crohn's disease and postoperative adhesions who have acute-onset severe nausea and vomiting.
INVESTIGATIONS
Colonoscopy with intubation of the ileum: shows aphthous ulcers, hyperaemia, oedema, cobblestoning, and skip lesions.
Ulcerative colitis
SIGNS / SYMPTOMS
Altered bowel movements (usually diarrhoea) and haematochezia.
INVESTIGATIONS
Flexible sigmoidoscopy: shows rectal involvement, continuous uniform involvement, loss of vascular marking, diffuse erythema, mucosal granularity, fistulas (rarely seen), and normal terminal ileum (or mild 'backwash' ileitis in pancolitis).
Median arcuate ligament syndrome
SIGNS / SYMPTOMS
Causes chronic, recurrent postprandial epigastric pain, related to compression of the coeliac artery by the median arcuate ligament. May be accompanied by nausea, vomiting, or diarrhoea and/or weight loss. On examination of the abdomen, an epigastric bruit that is louder with expiration may be heard.[76]
INVESTIGATIONS
Coeliac artery narrowing or obstruction is seen on Doppler ultrasound, MRI, magnetic resonance angiography (MRA), computerised tomography angiography (CTA), and/or visceral angiography.[76]
Superior mesenteric artery syndrome
SIGNS / SYMPTOMS
Caused by compression of the third portion of the duodenum between the superior mesenteric artery (SMA) and the aorta. Presents with symptoms of proximal small bowel obstruction. Patients with mild obstruction may have postprandial epigastric pain and early satiety. Those with more advanced obstruction may have severe nausea, bilious vomiting, and weight loss. Symptoms are worse when patient is supine and better in a prone, knee to chest, or left lateral decubitus position.
Findings on physical examination are non-specific but can include abdominal distension, a succussion splash, and high-pitched bowel sounds.[77]
INVESTIGATIONS
Upper gastrointestinal barium study shows gastroduodenal dilation, delayed gastroduodenal emptying, and a vertical, linear, band-like defect across the third portion of the duodenum due to vascular compression by the SMA. Other findings include a characteristic 'to and fro' pattern of peristalsis, commonly described as antiperistaltic flow, of the enteric contents proximal to the obstruction.
CT findings of SMA syndrome include a narrowed aorto-mesenteric angle, a decreased aorto-mesenteric distance, and gastroduodenal dilation with an abrupt narrowing in bowel calibre at the SMA take-off from the aorta.[77]
Intestinal pseudo-obstruction
SIGNS / SYMPTOMS
A rare disorder characterised by an impairment of co-ordinated propulsive activity in the gastrointestinal (GI) tract, which clinically mimics mechanical intestinal obstruction. The most frequent symptoms and signs are abdominal pain (which is particularly severe during acute episodes) associated with bloating and distension. Upper GI involvement may cause nausea, vomiting, and weight loss, while more distal disease may result in diffuse abdominal pain, abdominal distension, and constipation. Clinical examination may reveal a succussion splash, a hypertympanic percussion note, and occasionally intestinal loop contractions that may be visible upon inspection of the abdomen. Direct GI features mimicking obstruction typically present as recurrent sub-occlusive episodes characterised by sudden onset of intense pain, cramping, abdominal distension, nausea, and vomiting.[78]
INVESTIGATIONS
Plain film abdominal x-ray may demonstrate the classic sign of dilated bowel loops with air-fluid levels.[78]
Cannabinoid hyperemesis syndrome
SIGNS / SYMPTOMS
A syndrome of cyclic vomiting associated with cannabis use. History reveals at least weekly cannabis use for greater than 1 year, severe nausea and vomiting that recurs in a cyclic pattern over months and is usually accompanied by abdominal pain, resolution of symptoms after stopping cannabis, and compulsive hot baths/showers with symptom relief.[79]
INVESTIGATIONS
No specific differentiating tests. Up to 30% of patients may show delayed gastric emptying on gastric emptying scintigraphy.[79]
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