gastroparesis is a condition of impaired gastric emptying without evidence of gastric outlet obstruction . this disorder is characterized by a poor quality of life and nutritional deficits and is associated with symptoms such as nausea , vomiting , postprandial fullness , early satiety , and bloating [ 13 ] . gastroparesis is a heterogeneous disorder most often idiopathic , diabetic , or postsurgical in nature , affecting up to 1.8% of the population . diabetic gastroparesis ( dg ) affects patients with long - standing diabetes mellitus usually complicated by retinopathy , neuropathy , and nephropathy . for example , h. pylori infection has been reported to increase , decrease [ 5 , 6 ] , or not influence [ 710 ] the likelihood of delayed gastric emptying . idiopathic gastroparesis has been described predominantly in young female patients with low - normal body mass . the predictive value of dyspeptic symptoms is also the subject of ongoing study [ 1117 ] . recently , a gastroparesis cardinal symptom index ( gcsi ) has been developed as a valid tool for symptom stratification and for the evaluation of treatment response [ 3 , 18 ] . nevertheless , precise clinical correlates of gastroparesis remain elusive . in the first study of its sort from our geographical region , we attempt to further define the predictors of delayed gastric emptying in patients undergoing gastric emptying scintigraphy ( ges ) at our tertiary referral center . this single - center study was conducted in accordance with the principles of the declaration of helsinki and good clinical practice ( gcp ) and was approved by the human subjects protection program of the rabin medical center ( rmc ) . dyspeptic patients undergoing ges at our institution between january 2003 and december 2009 were retrospectively identified using an established computerized chart . only patients examined at the gastroenterology outpatient clinic and referred to ges by a gastroenterologist were included . similarly , only subjects who had undergone upper gastrointestinal endoscopy within 1 year of ges were included . this was to ensure that no patients had gastric outlet obstruction as a cause of their symptoms . the following cases were excluded : patients with established gastroparesis undergoing follow - up ges , cases lacking h. pylori testing by histology , rapid urease test , or c-13 urea breath test within 3 months of ges , gastric outlet obstruction , active malignancy , pregnancy , age below 18 years , and incomplete medical records . the following parameters were obtained from the patients ' electronic record : age , sex , symptoms ( dysphagia , early satiety , nausea , vomiting , bloating , abdominal pain , heartburn , and regurgitation ) , smoking , other active health problems including ischemic heart disease , gastroesophageal reflux disease , rheumatologic disease including scleroderma , endocrine disease including diabetes mellitus ( noting microvascular complications ) , and thyroid disease , current medications including antireflux , opioid analgesics , and promotility agents . the electronic records retrieved included admission data , clinic visits , billing claims data , icd-9 diagnoses registered in the centralized database , and pharmacy claims . all data were obtained by two independent reviewers ( doron boltin and ibrahim zvidi ) . missing parameters were obtained by a phone interview ( ibrahim zvidi ) . following a 14-hour fast patients received a standard 250  kca meal consisting of an egg fried in 5  g margarine , 2 slices of white bread , and 200  ml of water ( 15  g proteins , 26  g carbohydrates , and 9  g fat ) . isotope labeling was performed by adding 1  mci of tc - sulphur colloid to the egg white . fixation of the tracer to the solid phase ( necessary for measuring gastric emptying of solids ) was accomplished by dissolving the isotopes inside the egg and solidifying the egg . sequential - conjugated anterior - posterior view scintigrams of the epigastric area were acquired in a sitting position on a dual head gamma camera ( milennium vg and infinia , ge , buckinghamshire , uk , and e.cam , siemens , buckinghamshire , uk ) at 30 , 60 , and 120 minutes following ingestion of the standardized test meal . after 2008 , delayed scans were performed at 180 and 240 minutes in accordance with guidelines published at that time . to analyze the scintigraphy results the gastric region of interest ( roi ) was manually drawn around the stomach on the frames at the beginning of the dynamic scan . a time - activity curve was generated from the roi and was corrected for radioisotope decay . a linear fit of the time activity curve was used to calculate the gastric emptying half - time ( gastric t1/2 ) . a gastric t1/2 greater than 100 minutes was considered abnormal . gastric retention , a recently introduced method to define gastric emptying rate , is considered by most authors as a better method to assess gastric emptying rate ( ger ) . gastric retention greater than 10% after 4 hours is considered abnormal . in this study , however , assessment of gastric retention of tracer was feasible only after 2008 and for this reason we used gastric t1/2 for statistical analyses . due to the presence of incalculable t1/2 values for gastric emptying ( excessively prolonged ) data was categorized into 3 groups as opposed to a continuum . univariate analysis was performed for each of the acquired variables after sorting patients according to their h. pylori status and gastric emptying . categorical variables including sex , clinical diagnosis , h. pylori infection , and t1/2 were analyzed with pearson 's  test and fischer exact test . mann - whitney u test was used for symptom scores . as dependent variables we considered either individual symptom scores or the cumulative scores of symptoms . all possible cutoff values of the scores for these dichotomous variables were considered in the analysis . p values of 0.10 and 0.15 were chosen as cutoff points to enter and exit the stepwise procedure . odds ratios ( or ) with 95% confidence intervals ( ci ) were computed by means of  analysis only for the independent variables that entered the model . a cutoff value of 40  yr was chosen for age . during the study period , 420 dyspeptic patients underwent ges at our institution of whom 193 ( 46% ) were eligible for inclusion in the study ( 76 ( 39% ) males , mean age 60.15  15.61 years ) . there was a preponderance of females in all groups which did not correlate with t1/2 values . relevant past medical history included type ii diabetes mellitus in 79 patients ( 40.9% ) , scleroderma in 14 patients ( 7.3% ) , and previous esophageal / gastric surgery in 19 patients ( 9.8% ) . the t1/2 for gastric emptying was normal ( 099 minutes ) in 101 patients ( group 1 ) , abnormal ( 100299 minutes ) in 67 patients ( group 2 ) , and excessive ( 300 minutes ) in 25 patients ( group 3 ) . we found a significant association between prolonged gastric t1/2 and presenting symptoms of dysphagia or vomiting and the use of antisecretory or promotility agents ( figure 1 ) . diabetes was associated with significantly more excessive results ( group 3 ) compared to group 2 ( or 1.98 ( 0.775.00 ; p = 0.03 ) ) ; however , when compared to patients with normal gastric emptying ( group 1 ) , diabetes was not more common ( figure 2 ) . there was no significant correlation between gastric t1/2 and patient age , gender , or h. pylori infection . subgroup analysis demonstrated that patients with idiopathic gastroparesis were significantly younger than their counterparts with gastroparesis secondary to diabetes , surgery , or scleroderma ; however , no difference in sex , h. pylori infection , or any other predictor was observed ( table 3 ) . in the present study we describe the demographic and clinical predictors of gastroparesis in a cohort of consecutive dyspeptic patients referred for gastric scintigraphy at a single tertiary referral center . our center is the largest hospital belonging to clalit health services , the largest of five health care providers in the country with approximately 3.8 million members . of all the presenting symptoms in subjects referred for scintigraphy , only dysphagia and vomiting were independent predictors of a delayed gastric t1/2 . these findings concur with ardila - hani et al .   who found positive correlation between vomiting and anorexia and delayed gastric t1/2 . others have found that postprandial fullness , bloating , and pain correlate with delayed gastric emptying , but not vomiting or dysphagia [ 15 , 20 ] . ron et al . found that early satiety was the only patient - reported symptom associated with delayed gastric emptying , as assessed by breath - test . prospective studies using validated scoring systems have correlated protean symptoms with gastric retention ; however , a wide variability exists [ 1113 , 16 ] . in fact , delayed gastric emptying rate ( ger ) is not always associated with symptoms . indeed , gastric t1/2 is not a very specific marker of gastric dysmotility , and it has been found to be surprisingly normal in some dyspeptic patients with long - standing diabetes mellitus . dysphagia , as a predictor of gastric emptying has not been reported by other groups , is not a classic manifestation of gastroparesis and indeed is not a component of the gcsi . our computerized charts allowed for reliable reporting of dysphagia . nevertheless , this finding may be biased by an overrepresentation of scleroderma and upper gi surgery cases ( in whom dysphagia was reported in 21% , compared to 11% in diabetic and idiopathic cases ) or an overrepresentation of patients with gerd ( in whom dysphagia was noted in 13.8% , compared to 9.1% without gerd ) . so , too , our exclusion of patients without upper gi endoscopy within 12 months of ges may have led to the overrepresentation of alarm symptoms such as dysphagia . we found no correlation between prolonged gastric emptying and h. pylori infection , either as a whole group or in the subset of patients with idiopathic gastroparesis . this is in keeping with several older studies which have discounted a specific link between h. pylori and idiopathic gastroparesis [ 22 , 23 ] . although a minority of studies have linked h. pylori infection to increased or decreased gastric emptying , these studies are limited by inaccurate definitions of dyspepsia , small case numbers , nonstandardized symptom questionnaires , and methodological flaws such as the use of low - calorie test meals [ 5 , 6 , 24 ] . over diabetes is a well - described cause of gastroparesis ( 29% ) and the incidence of gastroparesis is 4.5% and 1.0% in types i and ii diabetes , respectively . diabetic gastroparesis may be related to autonomic neuropathy , enteric neuropathy , interstitial cells of cajal dysfunction , acute hyperglycemia , incretin - based medications , and altered neuroendocrine function . in this study , patients with a markedly abnormal gastric t1/2 ( 300  mins ) were almost twice as likely to have diabetes mellitus , when compared to subjects with lesser degrees of gastroparesis ( 100  mins  t1/2 < 300  mins ) . interestingly , a similar relationship was not observed when compared to patients with normal gastric emptying ( t1/2 < 100 ) ( table 2 ) . this may reflect a referral bias to scintigraphy for diabetic patients with upper gastrointestinal symptoms , leading to an overrepresentation of diabetic subjects in group 1 . alternatively , this may be a reflection of relatively well - controlled diabetes in study population ( mean hba1c was 7.7% ) or preemptive treatment with promotility agents . subanalyses did not reveal any difference in gastric t1/2 between diabetic subjects with or without microvascular complications . this is probably a confounding factor , simply representing a subset of patients with severe symptoms . this likely represents ( inadequate ) treatment in patients with a high pretest probability for gastroparesis . suffice it to say , current recommendations call for stopping all medications known to affect gastric emptying for 4872 hours ; however , due to the retrospective nature of our study it is impossible to know if this was enforced . subgroup analysis revealed that patients with idiopathic gastroparesis were significantly younger than their counterparts with diabetes , previous surgery , or rheumatic disease . two - thirds of subjects with idiopathic gastroparesis were female , compared to approximately half of subjects with normal gastric emptying . this is consistent with parkman et al . who found that idiopathic gastroparesis occurs predominantly in young female patients with low - normal body mass [ 11 , 27 ] . the underlying mechanism for this phenomenon is not fully understood and may be related to estrogen levels . indeed , during the ovulatory period and pregnancy , peristalsis is decreased and constipation is commonly reported . parkman , however , described a cohort providing no comparison to other forms of gastroparesis or to subjects undergoing ges without gastroparesis . our study has several limitations , including the retrospective design and the absence of validated symptom questionnaires such as the gcsi . nevertheless , every attempt was made to retrieve data on symptoms retrospectively in a thorough manner . all of the symptoms mentioned in section 2 were included in the analysis and only vomiting and dysphagia were found to be independent predictors . no reliable data on body mass index ( bmi ) could be extracted from the electronic files . another limitation is our inclusion of variables which may affect gastric emptying in unpredictable and unquantifiable manner . data was partially obtained from scans performed prior to 2009 at which time a standardized test protocol ( minimum 4-hour testing ) was adopted . for this reason extrapolated t1/2 values were used to quantify gastric emptying as opposed to the directly measurable percentage of tracer retained . this in turn precluded regarding gastric emptying as a continuous variable , as 12t1/2 values were  infinite . there is currently no data regarding what constitutes normal or abnormal gastric emptying in these patients . in conclusion , this study identifies that vomiting and dysphagia but not bloating or early satiety are independent predictors of prolonged gastric emptying .
background . 
 gastroparesis is a heterogeneous disorder most often idiopathic , diabetic , or postsurgical in nature . 
 the demographic and clinical predictors of gastroparesis in israeli patients are poorly defined . 
 methods . during the study period we identified all adult patients who were referred to gastric emptying scintigraphy ( ges ) for the evaluation of dyspeptic symptoms . of those , 
 193 patients who were referred to ges from our institution were retrospectively identified ( 76 ( 39% ) males , mean age 60.2  15.6 years ) . 
 subjects were grouped according to gastric half - emptying times ( gastric t1/2 ) . 
 demographic and clinical data were extracted from electronic medical records or by a phone interview . 
 key results . 
 gastric emptying half - times were normal ( gastric 
 t1/2 099  min ) in 101 patients , abnormal ( gastric t1/2 100299  min ) in 67 patients , and grossly abnormal ( gastric t1/2  300  min ) in 25 patients . 
 vomiting and dysphagia , but neither early satiety nor bloating , correlated with delayed gastric emptying . 
 diabetes was associated with grossly abnormal gastric t1/2 . 
 idiopathic gastroparesis was associated with a younger age at ges . 
 no correlation was observed between gastric 
 t1/2 values and gender , smoking , h. pylori infection , hba1c , or microvascular complication of diabetes . 
 conclusions inferences . 
 vomiting and dysphagia are predictive of delayed gastric emptying in both diabetic and nondiabetic subjects . 
 diabetes is associated with more severe gastroparesis .