Gastroparesis Management Guidelines

Diagnosis and Evaluation

• Gastroparesis is diagnosed based on the presence of clinical symptoms (nausea, vomiting, early satiety, postprandial fullness, bloating, upper abdominal pain) and documentation of delayed gastric emptying in the absence of mechanical obstruction. 1, 2
• Gastric emptying scintigraphy of a radiolabeled solid meal is the best accepted method to test for delayed gastric emptying, with a 4-hour test duration recommended to increase diagnostic yield. 1
• Antroduodenal manometry may help differentiate between neuropathic or myopathic motility disorders and can diagnose unexpected small bowel obstruction or rumination syndrome. 3, 4

First-Line Treatment Approach

• The American Gastroenterological Association recommends primary treatment of gastroparesis through dietary modifications, antiemetic agents, and prokinetic medications, with metoclopramide being the only FDA-approved medication for this condition. 5, 3, 4
• Eat frequent smaller-sized meals and replace solid food with liquids (such as soups). 5
• Foods should be low in fat and fiber content. 5, 4
• Antiemetic agents are administered for nausea and vomiting. 5
• Principal classes of antiemetic agents include:
  • Antidopaminergics (prochlorperazine, trimethobenzamide, promethazine) 5
  • Antihistamines 5
  • Anticholinergics 5
  • Serotonin (5-HT3) receptor antagonists - best used on an as-needed basis 5

Management of Refractory Gastroparesis

• Medically refractory gastroparesis is defined as persistent symptoms despite dietary adjustment and metoclopramide therapy. 6
• Treatment should be tailored based on the predominant symptom (nausea/vomiting vs. abdominal pain/discomfort) and symptom severity. 7
• For nausea/vomiting predominant symptoms:
  • Mild: Anti-emetic agents 7
  • Moderate: Combination of anti-emetic and prokinetic agents, cognitive behavioral therapy/hypnotherapy, liquid diet 7
  • Severe: Consider enteral feeding (J tube) or gastric electrical stimulation 7
• For abdominal pain/discomfort predominant symptoms:
  • Treat similar to functional dyspepsia 7
  • Consider augmentation therapy for moderate symptoms 7
  • Address comorbid affective disorders 7
• Metoclopramide is the first-line prokinetic agent and only FDA-approved medication for gastroparesis. 6
  • Standard dosing: 10 mg three times daily before meals for at least 4 weeks. 6
  • Clinicians should be aware of the black box warning for tardive dyskinesia, although risk may be lower than previously estimated. 6
• Alternative prokinetic agents include:
  • Erythromycin - can be administered orally or intravenously 5
  • Domperidone - a dopamine (D2) receptor antagonist (not FDA-approved in the United States but available in Canada, Mexico, and Europe) 5
• Intrapyloric botulinum toxin injection is not recommended based on placebo-controlled studies showing no benefit. 8
• Gastric per-oral endoscopic myotomy (G-POEM) should only be performed at tertiary care centers by experts in treating refractory gastroparesis. 8

Treatment Algorithm for Gastroparesis

• Confirm diagnosis with gastric emptying study 1
• Implement dietary modifications and start metoclopramide (if no contraindications) and appropriate antiemetics
• For diabetic patients, optimize glycemic control
• If symptoms persist after 4 weeks of optimal therapy, consider:
  • Alternative or combination prokinetic agents 5
  • Intensified antiemetic therapy 5
• For truly refractory cases, consider referral to a tertiary center for:
  • Gastric electrical stimulation 3
  • Enteral feeding via jejunostomy
  • Consideration of emerging endoscopic therapies 3

Management of Gastroparesis

Dietary and Pharmacologic Interventions

• Small particle size diet may improve key symptoms in patients with gastroparesis, as recommended by the American Diabetes Association 9
• Treatment should be limited to 12 weeks due to risk of serious adverse effects including extrapyramidal symptoms and tardive dyskinesia, according to the American Diabetes Association 9
• Withdraw medications that may worsen gastroparesis, including opioids, anticholinergics, tricyclic antidepressants, GLP-1 receptor agonists, and pramlintide, as suggested by the American Diabetes Association 9
• Gastric per-oral endoscopic myotomy (G-POEM) should only be performed at tertiary care centers by experts in treating refractory gastroparesis, as recommended by the American Gastroenterological Association 10