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  • Updated Guidelines for Gastroparesis
    When the movement of food from the stomach to small intestine is slowed or stopped, and there is no mechanical obstruction, symptoms will usually develop. These epigastric symptoms, including nausea, vomiting, premature satiation, or uncomfortable fullness in the abdomen, help distinguish the disorder referred to as gastroparesis. With no cure, the condition can result in a wide range of physical responses and can become serious and debilitating. The timely journal publishing of a revised clinical guideline during August's Gastroparesis Awareness Month helps increase the focus and attention on this somewhat overlooked condition.

    The newly revised guideline offered by the American College of Gastroenterology (ACG) updates its last iteration from 2013. The new 2022 clinical guideline was released in the August edition of The American Journal of Gastroenterology. In it, the authors sought to summarize current perspectives on the risks, diagnosis, and management of gastroparesis in adult patients. Understanding the condition and the approaches to controlling and easing its effects on patients are crucial. The commonly quoted prevalence is 5 million adults in the US having gastroparesis, with some estimates reaching 8 to 10 million. There often will not be a cause identified in a patient, but there are connections to diabetes, development post-surgery (such as stomach surgery), certain infections, or being an adverse effect of medications that delay stomach emptying. Concomitant disorders and painful symptoms that are possible with gastroparesis often lead patients to express a dramatically decreased quality of life. The ACG guideline explores the approaches to addressing the condition, offering multi-layered management that includes dietary aspects, pharmacological options, device utilization, and interventions directed at the pylorus.

    The diagnosis through treatment algorithm within the guideline expands upon the simpler 2013 version. It begins with identification of the symptoms of gastroparesis (chronic nausea, vomiting, postprandial fullness, bloating, upper abdominal discomfort). Iatrogenic disease should be excluded (for example, the use of opiates). Regarding diagnosis, three recommendations included are:
    • Exclude mechanical obstruction via esophagogastroduodenoscopy/radiology. Note that mechanical obstructions may occur when food is retained too long in the stomach and a bezoar forms.
    • 4h Solid gastric emptying or 13C-spirulina gastric emptying breath test (this non-radioactive test uses labeled food where the patient provides breath samples for analysis).
    • Measurement of extra-gastric dysmotility, eg, use of wireless motility capsule (a SmartPill, which is a capsule that contains a small electronic device that records as it travels through the stomach and intestine), pan-gastrointestinal scintigraphy (gastric emptying scintigraphy of a solid-phase meal is considered to be the standard for diagnosis of gastroparesis, as it quantifies the emptying of a physiologic caloric meal).
    After diagnosis, management begins with planning dietary modifications with patients. The recommendations are for small particle, low fat, low non-digestible food. Compared to a normal diet, these modifications offer relief of gastroparesis symptoms, improving gastric emptying and increasing glycemic control.

    The guidelines also delve into pharmacological treatment, covering the current categories of medicines available.
    • Prokinetics ( metoclopramide, short-term use of erythromycin [this antibiotic accelerates gastric emptying by binding to motilin, thereby stimulating cholinergic activity in the antrum and initiating phase III contractions of the migrating motor complex], domperidone [patients may be able to receive treatment with domperidone through expanded access use via an investigational new drug application], others).
    • Antiemetics (histamine H1 or 5-HT3 antagonists that offer symptom control but do not improve gastric emptying, such as ondansetron or granisetron).
    • Pain/other symptom relief, avoiding opioids (eg, central neuromodulators are not recommended).
    When needed, such as in cases of malnutrition and dehydration, nutritional support is recommended, suggesting enteral, rarely parenteral.

    Non-pharmacological treatment options are also covered within the guideline:
    • Pyloromyotomy/pyloric injection botulinum toxin (intrapyloric injection of botulinum toxin is not recommended for patients with gastroparesis based on randomized, controlled trials)
    • Gastric per-oral endoscopic myotomy (G-POEM) (This is a specialized procedure done in patients unresponsive to or unsuccessful with other therapies. It is a minimally invasive endoscopic stomach surgery that entails creating an incision in the pylorus, creating a channel to the small intestine), laparoscopic pyloroplasty (this procedure widens the opening at the bottom of the stomach)
    • Gastric electrical stimulation (this surgically implanted device may be considered for control of gastroparesis symptoms as a humanitarian use device)
    • Venting gastrostomy (helps relieve pressure from gastric contents), feeding jejunostomy (for patients unable to tolerate any food or liquids)
    • Partial gastrectomy, sleeve gastrectomy
    All providers could benefit from increased familiarity with the hallmarks of gastroparesis in order to more quickly identify patients with the disorder and help begin treatment to improve their health outcomes. Read the full updated guideline, and consider participating in the ACG Annual Scientific Meeting & Postgraduate Course in October 2022. Within the bonus session of Gastroparesis and Functional Dyspepsia in 2022 will be a guideline-specific presentation entitled The Latest and Greatest: ACG's New Gastroparesis Guidelines. In addition, stay informed about emergent drug information, including treatment options for gastroparesis, by updating or registering your profile to receive email alerts and other critical drug information updates from PDR. You can also stay current by using the official PDR app, mobilePDR, available for free from your favorite app stores.