Guideline sources The following summarized guidelines for the evaluation and management of gastroparesis (GP) are prepared by our editorial team based on guidelines from the American College of Gastroenterology (ACG 2022; 2013), the American Gastroenterological Association (AGA 2022), the European Society for Neurogastroenterology and Motility (ESNM/UEG 2021), and the European Society of Gastrointestinal Endoscopy (ESGE 2020). 1 2 3 4 5 6 6 6 6 6 Definition GP is a syndrome characterized by delayed gastric emptying and symptoms thereof in the absence of gastric outlet obstruction. 6 Epidemiology GP is most frequently caused by diabetes mellitus neuropathy and idiopathic causes. Other causes include iatrogenic vagotomy (surgery for peptic ulcer disease, fundoplication), post-infection, CNS diseases (stroke, other causes of autonomic neuropathy, Parkinson's disease, spinal cord injury), paraneoplastic syndrome, polymyositis, scleroderma, drugs (opiates, anticholinergic drugs), https://web.pathway.md/diseases/recclytopqFECMeFt 1/7 6/24/23, 3:16 AM Gastroparesis Pathway metabolic disorders (hypothyroidism, hyperparathyroidism, Addison's disease), lung transplantation, anorexia nervosa, and pregnancy. 6 Pathophysiology The incidence of GP in the United States women and men is estimated at 9.8 per 100,000 person- years and 2.4 per 100,000 person-years, respectively. 6 Disease course Clinical manifestations include nausea, vomiting, upper abdominal pain or discomfort, early satiety, postprandial fullness, bloating, heartburn, and dysphagia. Severe disease is related to depression, anxiety, increased hospitalizations, medication, or tube feeding decreasing quality of life. 6 Prognosis and risk of recurrence GP independently is not associated with increased mortality. 6 Guidelines 1. Screening and diagnosis Clinical presentation: Recognize that: GP refers to a symptom or set of symptoms associated with delayed gastric emptying A and severely disturbed gastric motor function in the absence of mechanical obstruction B nausea and vomiting are cardinal symptoms of GP B dyspeptic symptoms, such as postprandial fullness, early satiation, epigastric pain, as well as bloating in the upper abdomen and belching are often present in GP B symptoms in GP overlap mainly with postprandial distress syndrome and less with epigastric pain syndrome symptoms of functional dyspepsia B GP is associated with a significant decrease in quality of life A GP is associated with psychosocial comorbidities, such as anxiety and depression. A Diagnosis: diagnose GP based on the combination of symptoms of GP, absence of gastric outlet obstruction or ulceration, and delay in gastric emptying. A Differential diagnosis: As per AGA 2022 guidelines, review symptoms and perform a physical examination to exclude disorders possibly mimicking medically refractory GP. B As per UEG 2021 guidelines: Exclude eating disorders in case of weight loss. B Consider obtaining imaging to exclude small bowel obstruction. C As per ACG 2013 guidelines, consider evaluating for the presence of GP in patients with GERD refractory to acid-suppressive treatment. C https://web.pathway.md/diseases/recclytopqFECMeFt 2/7 6/24/23, 3:16 AM Gastroparesis Pathway Show 3 more 2. Classification and risk stratification Risk factors: Recognize that the following conditions are associated with an increased risk for the development of GP: diabetes A partial gastric resection/vagotomy, bariatric surgery, and antireflux surgery B certain neurological disorders, such as Parkinson's disease, multiple sclerosis, and amyloid neuropathy B certain connective tissue diseases B certain drugs, such as opioids. A Recognize that the prognosis of GP depends on the cause. B Severity assessment: classify patients with GP into mild, moderate, or severe based on symptoms and the results of a properly performed gastric emptying study. B 3. Diagnostic investigations Pre-test preparation: Discontinue medications affecting gastric emptying at least 48 hours before diagnostic testing, or > 48 hours before testing depending on the pharmacokinetics of the medication. A Measure blood glucose level in patients with diabetes before gastric emptying testing, and treat hyperglycemia with a test started after blood glucose is < 275 mg/dL. B Gastric emptying studies, modalities: As per ACG 2022 guidelines, obtain scintigraphic gastric emptying as the first-line test for the evaluation of GP in patients with upper gastrointestinal symptoms. B Show 3 more As per ESNM/UEG 2021 guidelines: Obtain gastric emptying testing to establish a diagnosis of GP. A Obtain scintigraphic gastric emptying or breath test assessment as a valid test for diagnosing GP. A Gastric emptying studies, methodology: As per ACG 2022 guidelines, ensure appraising the emptying of a solid meal over 3 hours during scintigraphic gastric emptying. B As per AGA 2022 guidelines, verify the appropriate methodology of the gastric emptying study to ensure an accurate diagnosis of delayed gastric emptying. B Functional lumen imaging probe: consider obtaining endoluminal functional lumen imaging probe evaluation for characterizing pyloric function and predicting treatment outcomes after https://web.pathway.md/diseases/recclytopqFECMeFt 3/7 6/24/23, 3:16 AM Gastroparesis Pathway peroral pyloromyotomy in patients with GP. C Evaluation for underlying cause: screen patients with GP for the presence of diabetes mellitus, thyroid dysfunction, neurological disease, prior gastric or bariatric surgery, and autoimmune disorders. A Show 3 more 4. Diagnostic procedures Upper gastrointestinal endoscopy: perform upper gastrointestinal endoscopy to establish a diagnosis of GP. A 5. Medical management General principles: As per ACG 2022 guidelines, consider offering pharmacotherapy to improve gastric emptying and GP symptoms in patients with idiopathic and diabetic GP, taking into account the benefits and risks of treatment. C As per AGA 2022 guidelines: Identify the predominant symptom and initiate treatment based on that symptom. B Recognize the multiple treatment options available for the management of nausea and vomiting. B Cessation of precipitating medications: Discontinue narcotics and other medications delaying gastric emptying to establish the diagnosis with a gastric emptying test. A Consider discontinuing pramlintide and GLP-1 agonists before initiation of therapy for GP in patients taking these medications, as they have been associated with delayed gastric emptying. C Glycemic control: consider ensuring optimal glucose control to reduce the future risk of aggravation of GP in patients with diabetic GP. C Prokinetics and antiemetics: As per ACG 2022 guidelines, consider offering metoclopramide for the management of refractory symptoms in patients with GP. C Show 3 more As per UEG 2021 guidelines, offer dopamine-2 antagonists and 5-HT4 agonists for the management of patients with GP. B Neuromodulators: As per ACG 2022 guidelines, do not use central neuromodulators for the treatment of patients with GP. D https://web.pathway.md/diseases/recclytopqFECMeFt 4/7 6/24/23, 3:16 AM Gastroparesis Pathway As per AGA 2022 guidelines, consider offering neuromodulators for the treatment of GP- associated abdominal pain. Do not use opioids. C Ghrelin agonists: do not use ghrelin agonists for the treatment of patients with GP. D Haloperidol: do not use haloperidol for the treatment of patients with GP. D 6. Nonpharmacologic interventions Dietary therapy: As per ACG 2022 guidelines, offer a small particle size diet as dietary management of GP to increase likelihood of symptom relief and enhance gastric emptying. B As per UEG 2021 guidelines: Implement dietary adjustments for managing patients with GP. B Provide nutritional support in the form of enteral or parenteral nutrition in case of severe weight loss or intractable vomiting. B As per ACG 2013 guidelines, refer patients to a dietitian for counseling regarding consumption of frequent small volume nutrient meals low in fat and soluble fiber. B Show 5 more Acupuncture: consider offering acupuncture, alone or acupuncture in combination with prokinetic drugs, for symptom control in patients with diabetic GP. Do not offer acupuncture for other etiologies of GP. C Herbal products: do not use herbal therapies, such as Rikkunshito or STW5 for the treatment of patients with GP. D 7. Therapeutic procedures Indications for endoscopic pylorus-directed therapies: consider offering endoscopic pylorus- directed therapies only in patients with symptoms suggestive of GP in combination with objective proof of delayed gastric emptying using a validated test, and only when medical therapy has failed. B Intrapyloric injection of botulinum toxin: As per ACG 2022 guidelines, do not administer intrapyloric injection of botulinum toxin in patients with GP. D As per ESGE 2020 guidelines: Do not use botulinum toxin injections for the treatment of unselected patients with GP. D Do not use botulinum toxin injection as the screening test to select patients for endoscopic pyloromyotomy or other pylorus-directed therapies. D Endoscopic pyloric dilation: avoid performing balloon dilation for the treatment of unselected patients with GP. D https://web.pathway.md/diseases/recclytopqFECMeFt 5/7 6/24/23, 3:16 AM Gastroparesis Pathway Endoscopic transpyloric stenting: do not perform transpyloric stenting for the treatment of patients with GP. D Gastric electrical stimulation: As per ACG 2022 guidelines, consider offering gastric electrical stimulation for symptom control in patients with GP. C As per AGA 2022 guidelines, consider offering gastric electrical stimulation in patients with GP and refractory/intractable nausea and vomiting failed standard therapy and not taking opioids. C 8. Perioperative care Perioperative antibiotic prophylaxis: administer prophylactic antibiotics during gastric POEM. Adapt the choice and duration of antibiotics according to national or local protocols. B 9. Surgical interventions Gastric peroral endoscopic myotomy: As per ACG 2022 guidelines, consider performing pyloromyotomy for symptom control in patients with GP with symptoms refractory to medical therapy. C As per AGA 2022 guidelines, consider performing gastric POEM in selected patients with refractory GP with severe delay in gastric emptying, using a thoughtful team approach involving motility specialists and advanced endoscopists at a center of excellence. C As per ESGE 2020 guidelines, consider performing gastric POEM only in carefully selected patients. Perform gastric POEM only in expert centers, preferably in the context of a clinical trial. B Show 3 more References 1. Jolien Schol, Lucas Wauters, Ram Dickman et al. United European Gastroenterology UEG and European Society for Neurogastroenterology and Motility ESNM consensus on gastroparesis. United European Gastroenterol J. 2021 Apr;9 3 287 306. Open 2. Camilleri M, Parkman HP, Shafi MA et al. Clinical guideline: management of gastroparesis. Am J Gastroenterol. 2013 Jan;108 1 18 37. Open 3. Michael Camilleri, Braden Kuo, Linda Nguyen et al. ACG Clinical Guideline: Gastroparesis. Am J Gastroenterol. 2022 Aug 1;117 8 1197 1220. Open 4. Brian E Lacy, Jan Tack, C Prakash Gyawali. AGA Clinical Practice Update on Management of Medically Refractory Gastroparesis: Expert Review. Clin Gastroenterol Hepatol. 2022 Mar;20 3 491 500. Open https://web.pathway.md/diseases/recclytopqFECMeFt 6/7 6/24/23, 3:16 AM Gastroparesis Pathway 5. Bas L A M Weusten, Maximilien Barret, Albert J Bredenoord et al. Endoscopic management of gastrointestinal motility disorders - part 1 European Society of Gastrointestinal Endoscopy ESGE Guideline. Endoscopy. 2020 Jun;52 6 498 515. Open 6. Adil E Bharucha. Epidemiology and natural history of gastroparesis. 2015 Mar;44 1 9 19.2015 Mar;44 1 9 19. Open 7. Adil E Bharucha. Epidemiology and natural history of gastroparesis. Gastroenterol Clin North Am. 2015 Mar;44 1 9 19. Open https://web.pathway.md/diseases/recclytopqFECMeFt 7/7