Diagnostic and Management Pathways for Gastric Motility and Vomiting Disorders
1.0 Initial Patient Assessment: Symptom-Based Triage
1.1. Introduction to Symptom-Directed Diagnosis
A meticulous clinical history is the cornerstone of an accurate diagnosis for upper gastrointestinal disorders. While imaging and physiological tests are essential, the patient's own description of their symptoms provides the critical initial roadmap. After a structural evaluation has ruled out obvious anatomical issues, the specific cluster of symptoms—what the patient feels, when they feel it, and what makes it better or worse—becomes the primary guide for selecting the most appropriate and high-yield diagnostic tests. This symptom-directed approach prevents unnecessary procedures and efficiently navigates the complex landscape of motility and functional GI disorders.
1.2. Symptom Cluster Triage Framework
The following framework provides initial clinical triage based on the dominant symptoms reported by the patient:
Primary Symptom: Dysphagia (Difficulty Swallowing)
Primary Symptom: Nausea with Early Satiety
Primary Symptom: Effortless Regurgitation
Primary Symptom: Episodic, Stereotyped Vomiting
Primary Symptom: Progressive Vomiting with Weight Loss
1.3. Concluding Transition
This initial symptom-based triage points toward a likely origin, but before proceeding with specialized motility testing, it is imperative to conduct a foundational evaluation to rule out any physical blockage, which is the universal first step in every diagnostic pathway.
2.0 Core Diagnostic Pathway: From Presentation to Diagnosis
2.1. The Foundational Role of Initial Evaluation
Ruling out a mechanical obstruction is the non-negotiable first step in the diagnostic workup. Symptoms of delayed gastric emptying can be caused by a functional motility issue or a physical blockage, such as a stricture or tumor. Labeling a patient with a motility disorder like gastroparesis before definitively excluding a mechanical cause is a critical diagnostic error. Therefore, the central pillar of the algorithm is to ensure the "pipes" are open before investigating the "pump."
Clinical Pearl: Gastroparesis is a diagnosis of normal anatomy plus delayed emptying. Gastric Outlet Obstruction is a diagnosis of abnormal anatomy plus impaired passage.
2.2. Step-by-Step Diagnostic Algorithm
Step 1: Exclude Mechanical Obstruction
The initial evaluation requires an Esophagogastroduodenoscopy (EGD) to exclude mechanical causes. The EGD allows for direct visualization to rule out intrinsic blockages like strictures, malignancy, peptic ulcer scarring, or bezoars.
If there is suspicion of extrinsic compression (e.g., from a pancreatic mass), a CT scan of the abdomen serves as a crucial adjunct to assess the anatomy surrounding the stomach and duodenum.
Step 2: Proceed Based on Normal EGD and Dominant Symptoms
After ruling out mechanical obstruction with a normal EGD, the clinician must select the next diagnostic test based on the dominant symptom profile.
A. If Dysphagia Dominates:
B. If Nausea, Early Satiety, and Postprandial Fullness Dominate:
C. If Effortless Regurgitation is the Key Feature:
D. If Episodic, Stereotyped Vomiting is the Pattern:
2.3. Concluding Transition
Following this structured diagnostic algorithm allows for the precise identification of the underlying disorder, which is the necessary prerequisite for creating a targeted and effective management plan.
3.0 Disorder-Specific Diagnostic Profiles
3.1. Introduction to Differentiating Key Syndromes
Understanding the distinct clinical signatures and underlying pathophysiology of each disorder is essential for accurate diagnosis. While symptoms can overlap, key features in the history, physical exam, and diagnostic testing allow for clear differentiation, which in turn guides targeted and effective therapy.
3.2. Profile: Gastroparesis vs. Functional Dyspepsia
These two conditions can present with nearly identical symptoms, but they are physiologically distinct.
Gastroparesis:
