Pan‐Alimentary Magnetic Resonance Imaging of Severe Gastroparesis May Facilitate Diagnosis and Treatment

A 51-year-old male patient with Type 1 diabetes and a diagnosis of gastroparesis, postprandial epigastric pain, nausea, and vomiting was investigated using a pan-alimentary magnetic resonance imaging (MRI) protocol. The protocol was developed as a way to gain useful information from several segments of the gut using a single test. The gold standard to determine orocecal time is considered to be gamma scintigraphy, imaging of a radioactive tracer, through the small bowel. However, this method is often inaccessible in less specialized hospitals due to limited availability of the radioactive tracer. Additionally, it exposes patients to radioactivity. Our protocol included static and dynamic MRI images of the stomach, small bowel, and colon [1]. Images were obtained during fasting and following a provocative 300 kcal liquid test meal of 400 mL nutrient drink. Three MRI transit markers were ingested 24 h before the MRI scan for assessment of whole gut transit [2]. At the baseline scan, a large amount of food remained in the stomach even though the patient was fasting overnight (Figure 1). Most of the food was placed in the antrum (Figure 1B), a finding that has been observed in other gastroparesis patients [3]. Furthermore, the three MRI transit markers were still present in the stomach 24 h after ingestion (Figure 1A), as compared to the expected position in the colon. The colon volume was large, consistent with constipation (Figure 2B). Following the test meal, postprandial motility was observed in the stomach and small intestine within normal ranges. Gastric half-emptying time was severely prolonged. However, gastric contraction amplitudes were larger than normally seen in healthy subjects (Figure 2A), challenging the diagnosis of “gastroparesis.” This suggested that a “downstream” problem caused the patient's symptoms and ultimately was caused by obstipation. As a result, treatment with lactulose, prucalopride, and amitriptyline was stopped and changed to bisacodyl 5 mg at night, with a pause every third day, and an enema with phosphate (8.2 g sodium phosphate and 21.9 g sodium acid phosphate) in the morning every other day. However, the patient's condition only improved slightly from the medication changes. Due to suspected pyloric stenosis consistent with the large gastric contraction amplitudes, an endoscopic dilatation of the pylorus was performed. This resulted in significant improvement of the epigastric symptoms, but after 2 months, they gradually reoccurred. Ultimately, an endoscopic pyloromyotomy was performed that relieved the postprandial symptoms. Martin Longhi Engelbrecht: writing – original draft. Nina Marie Videbech: investigation, writing – review and editing. Maja Veitland Ilkjær: investigation, writing – review and editing. Asbjørn Mohr Drewes: conceptualization, supervision, writing – review and editing. Esben Bolvig Mark: conceptualization, data curation, formal analysis, funding acquisition, project administration, writing – original draft. We obtained written informed consent for publication from the patient. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.