S5336 A Complex Case of Idiopathic Gastroparesis Presenting With Recurrent Hypoglycemia

Introduction: Gastroparesis refers to delayed gastric emptying and idiopathic gastroparesis remains the most significant etiology. Other causes include diabetes mellitus, iatrogenic, post-surgical, viral, neurological and myopathy. It is important to rule out mechanical obstruction, following scintigraphy, once the diagnosis has been established as highlighted in the case below. In addition to lifestyle modifications and prokinetic agents, managing the underlying disease process remains the mainstay for treatment. Case Description: Seventy-five-year-old man with past medical history of hypertension, DVT, pulmonary embolism (treated) who presented with shortness of breath, dyspnea, and heartburn for a year. During an endoscopy, Hill Grade III GEJ valve was found which was also previously noted on CT chest. Hence, the patient decided to undergo hiatal hernia repair. Patient developed worsening heartburn after the hiatal hernia repair, and also developed new symptoms of nausea and vomiting. Initial management comprised of symptom control with PPI, metoclopramide, and ondansetron, as well as dietary modifications. During this period he also developed symptomatic hypoglycemic episodes which resulted in syncopal episodes. Cardiac and neurological work up remained unremarkable. EGD evaluation of worsening symptoms revealed a large bezoar and narrow caliber pylorus which was difficult to traverse raising concern for functional gastric outlet obstruction. A gastric emptying study confirmed delayed emptying with 23% gastric emptying seen at 132 minutes. Other endocrine work up was unremarkable. Trial of botox injection 100 units/2 ml normal saline improved symptoms. Gastric Per-oral endoscopic myotomy was performed and subsequently resulted in normalization of blood glucose and improvement in symptoms. Discussion: This case underscores the importance of not only recognizing the clinical signs of gastroparesis but also pursuing a thorough evaluation to determine its etiology, as treatment strategies must be tailored to the underlying cause. Hypertrophic pyloric stenosis, although rare in adults, has been identified as a potential contributor to gastroparesis. Its pathophysiology remains incompletely understood. G-POEM has emerged as a highly effective intervention for gastroparesis secondary to pyloric dysfunction, with long-term success rates reported to be as high as 100% in select populations. This highlights its growing role in the therapeutic arsenal for patients with refractory gastroparesis.