Idiopathic Gastroparesis Treated with Gastric Peroral Endoscopic Pyloromyotomy Using Endolumenal Functional Lumen Imaging Probe

Abstract

Case: A 25-year-old man presented to the emergency clinic with epigastric pain. He was previously very healthy and served as a soldier. He developed abrupt epigastric pain and diarrhea three months prior to his initial visit. A doctor at the local clinic suspected infectious colitis and was prescribed an antibiotic at his first visit; however, there was no symptomatic improvements. He underwent colonoscopy, and intravenous hydrocortisone was prescribed under the impression of ulcerative colitis at the local clinic. This provided mild, transient symptomatic improvement and the patient was able to eat food. However, intermittent abdominal pain and nausea continued, and the patient lost 10 kg of weight during the first month. Later, the patient experienced abdominal pain, fever, and myalgia, and he was then referred to Asan Medical Center. His abdominal computed tomography (CT) scan showed a mild thickening of the gall bladder, but without stone. Under the impression of chronic cholecystitis, he underwent laparoscopic cholecystectomy. However, despite surgery, he still complained of chronic epigastric pain, nausea, and vomiting. He underwent upper endoscopy, which showed normal findings. Despite medical therapy with several prokinetics, including metoclopramide, he still experienced epigastric pain, nausea, and vomiting, resulting in more than 20 kg of weight loss during the last three months.Due to nausea and vomiting, he was unable to keep down any solid food, and required total parenteral nutrition. He was referred to the gastrointestinal (GI) clinic due to continuous abdominal pain, nausea, and vomiting without abnormal laboratory test results, including autoimmune antibodies and other inflammatory makers. To rule out gastric dysmotility disorder, gastric emptying scan (GES) was recommended.However, he was unable to eat the test meal for GES due to severe nausea. Instead of GES, he underwent barium upper GI series, which showed definite delayed barium passage at the pyloric ring (Fig. 1A, B). Electrogastrography revealed a representative image of gastric outlet obstruction (Fig. 2).