Gastroparesis

Establish gastroparesis only when upper gastrointestinal symptoms coexist with objective delayed gastric emptying and there is no mechanical obstruction at the gastric outlet. Exclude obstruction with upper endoscopy, abdominal imaging, or both before attributing nausea, vomiting, early satiety, or postprandial fullness to a motility disorder. The Lancet+3The LancetRome Foundation and international neurogastroenterology and motility societies’ consensus on idiopathic gastroparesisPubMedGastroparesis: A Review. - AbstractPubMedACG Clinical Guideline: Gastroparesis. - AbstractPubMedGastric Outlet Obstruction - StatPearls - NCBI Bookshelf

Order standardized solid-meal gastric emptying scintigraphy for suspected gastroparesis. Retention greater than 10% at 4 hours is diagnostic in the appropriate clinical setting; classify 4-hour retention of 10% to 15% as mild, 16% to 35% as moderate, and greater than 35% as severe. Do not rely on a 2-hour-only test, because current AGA guidance favors 4-hour testing. PubMed+2PubMedGastroparesis: A Review. - AbstractPubMedAGA Clinical Practice Guideline on Management of Gastroparesis. - AbstractPubMedHighlights From the New ACG Clinical Guideline for Gastroparesis

Use the FDA-approved carbon-13 spirulina stable-isotope breath test when scintigraphy is unavailable or impractical. Interpret it as an indirect test of gastric emptying because its validity depends on normal downstream intestinal, hepatic, and pulmonary handling of the labeled substrate. PubMed+1PubMedGastroparesis: A Review. - AbstractPubMedGastric Emptying Scan - StatPearls - NCBI Bookshelf

Review the medication list before assigning idiopathic disease. Discontinue or replace, when feasible, agents that delay gastric emptying, including opioids, cannabis, anticholinergics, and GLP-1 receptor agonists. Medication-induced gastroparesis is best managed by withdrawing the causative agent rather than by simply adding prokinetics. PubMed+1PubMedGastroparesis: A Review. - AbstractPubMedGastric Outlet Obstruction - StatPearls - NCBI Bookshelf

For diabetic gastroparesis, optimize glycemic control as part of treatment and avoid interpreting gastric emptying during marked hyperglycemia. HbA1c has been associated with 4-hour retention, although improved HbA1c over 6 months did not necessarily normalize gastric emptying in one cited study; use glucose optimization to reduce a modifiable contributor rather than as a substitute for symptom- and nutrition-directed treatment. Wolters Kluwer+1Wolters KluwerClinical Guideline: Management of Gastroparesis : American Journal of GastroenterologyPubMedACG Clinical Guideline: Gastroparesis

Document major etiologic context because diabetes, prior gastric surgery or vagal injury, medication exposure, neurologic disease, viral illness, autoimmune mechanisms, and idiopathic disease have different reversibility and escalation pathways. Idiopathic and diabetic disease are the populations specifically addressed by current AGA management guidance. ScienceDirect+1ScienceDirectNutritional approaches for gastroparesis - ScienceDirectPubMedAGA Clinical Practice Guideline on Management of Gastroparesis. - Abstract

Start with a small-particle diet—foods blended or chopped into small pieces—low in fat and nondigestible fiber. For mild disease, this dietary strategy plus antiemetics is a first-line approach; for severe disease, use a liquid diet or jejunal enteral feeding when oral solids cannot sustain nutrition. PubMedPubMedGastroparesis: A Review. - Abstract

Use antiemetics to control nausea and vomiting, recognizing that they relieve symptoms but do not correct gastric emptying. Serotonin 5-hydroxytryptamine-3 receptor antagonists and histamine H1 receptor antagonists are cited first-line antiemetic options for mild gastroparesis. PubMedPubMedGastroparesis: A Review. - Abstract

For moderate symptoms or persistent vomiting despite dietary modification and antiemetics, use a prokinetic. Current AGA guidance conditionally supports metoclopramide or erythromycin; metoclopramide remains the only medication approved in the United States for gastroparesis and is generally limited to less than 12 weeks. ScienceDirect+1ScienceDirectProkinetics in Gastroparesis - ScienceDirectPubMedAGA Clinical Practice Guideline on Management of Gastroparesis. - Abstract

Refer patients with persistent moderate-to-severe symptoms, recurrent vomiting, or nutrition failure despite medication withdrawal, dietary optimization, antiemetics, and a prokinetic trial to a motility-focused multidisciplinary center. Current AGA guidance recommends against routine initial G-POEM or gastric electrical stimulation, reserving them for selected medically refractory patients. PubMedPubMedAGA Clinical Practice Guideline on Management of Gastroparesis. - Abstract

Consider G-POEM after confirming absence of obstruction and delayed emptying on 4-hour scintigraphy. A 4-hour retention greater than 20% has been associated with a higher likelihood of response; nausea- and vomiting-predominant symptoms favor response, whereas pain-predominant symptoms are less likely to improve. Reported technical success exceeds 95%, with durable symptom relief in 50% to 77.5% at 2 to 4 years. PubMedPubMedRedefining the Treatment Landscape in Gastroparesis: A Clinical Review of Gastric Peroral Endoscopic Myotomy Outcomes and Therapeutic Integration

Consider gastric electrical stimulation for chronic intractable nausea and vomiting due to diabetic or idiopathic gastroparesis after medical therapy fails. Enterra received FDA humanitarian device exemption approval for this indication; evidence includes randomized data showing reduced refractory vomiting, but guideline recommendations reserve its use for selected refractory disease rather than routine early treatment. Wolters Kluwer+2Wolters KluwerClinical Guideline: Management of Gastroparesis : American Journal of GastroenterologyPubMedAGA Clinical Practice Guideline on Management of Gastroparesis. - AbstractGastroenterologyOn and Off of Gastric Electrical Stimulation for Refractory Vomiting - Gastroenterology

At follow-up, document vomiting frequency, ability to maintain oral fluids and calories, weight trajectory, hydration, electrolyte abnormalities, diabetes control when applicable, and use of drugs that slow emptying. Escalate nutrition support when oral intake fails rather than waiting for profound malnutrition. ScienceDirect+2ScienceDirectNutritional approaches for gastroparesis - ScienceDirectPubMedClinical guideline: management of gastroparesis - PubMedPubMedGastroparesis - StatPearls - NCBI Bookshelf

Recheck the diagnosis when symptoms are refractory but the initial study was confounded by hyperglycemia or motility-altering medications, or when the symptom phenotype is pain-, fullness-, or early-satiety predominant with normal emptying. The severity of delayed emptying does not uniformly predict symptom burden or response to therapy. Wolters Kluwer+2Wolters KluwerClinical Guideline: Management of Gastroparesis : American Journal of GastroenterologyPubMedTEN CONTROVERSIES IN GASTROPARESIS AND A LOOK TO THE FUTUREPubMedPharmacologic treatments for gastroparesis

For domperidone use under an investigational protocol, obtain baseline and follow-up ECGs and stop or avoid treatment when QTc exceeds the cited sex-specific thresholds. For metoclopramide, adhere to the recommended treatment duration of less than 12 weeks unless a carefully individualized risk-benefit decision supports otherwise. Wolters Kluwer+1Wolters KluwerClinical Guideline: Management of Gastroparesis : American Journal of GastroenterologyScienceDirectProkinetics in Gastroparesis - ScienceDirect