When Nausea and Vomiting Are Something Else Entirely, It's Not Gastroparesis: A Report of Two Cases

Gastroparesis, a chronic motility disorder, is a diagnosis of exclusion that necessitates careful evaluation for structural and surgically correctable causes. Although the medical differential diagnosis emphasizes functional etiologies, anatomic abnormalities are often under-recognized despite guideline recommendations for thorough endoscopic and structural assessment. Symptoms such as nausea, vomiting, early satiety, and delayed gastric emptying may be indistinguishable from true motility disorders. We present two patients initially diagnosed with gastroparesis whose symptoms were ultimately driven by surgical pathology. Case 1 describes a 70-year-old woman with persistent nausea and vomiting, weight loss, epigastric abdominal pain, and delayed gastric emptying on scintigraphy, initially scheduled for gastric peroral endoscopic myotomy (G-POEM) for presumed gastroparesis. Intraoperative endoscopy revealed gastric volvulus as the underlying etiology, prompting conversion to definitive surgical repair. Gastric volvulus, while rare, may be complicated by ischemia or perforation, highlighting the importance of timely differentiation from gastroparesis. Case 2 describes a 53-year-old woman with intractable nausea, vomiting, and inability to tolerate oral intake following a Roux-en-Y gastric bypass (RYGB). Surgical exploration revealed a Roux-en-O configuration with twisted limbs causing impaired drainage, ultimately requiring bypass reversal and pyloroplasty. The Roux-en-O configuration is a rare but serious complication of RYGB involving misplaced anastomoses that create a blind loop, resulting in obstruction and gastroparesis-like symptoms. Clinicians should maintain heightened suspicion for structural pathology in patients with atypical presentations, previous surgery, or refractory symptoms, as delayed diagnosis can lead to life-threatening complications.