The American College of Gastroenterology (ACG) released updated clinical guidelines on managing gastroparesis (GP). The new recommendations were published in The American Journal of Gastroenterology.
GP is characterized by delayed gastric emptying (GE) of solid food in the absence of mechanical obstruction. In 2013, the ACG published guidelines on GP management that included recommendations for prokinetic and antiemetic therapies, gastric electrical stimulation (GES), and centrally acting antidepressants as first-line treatment options.
The updated guidelines focus on risk factors, diagnosis, and treatment for GP.
Risk factors for Gastroparesis
Patients with diabetic GP are advised to maintain optimal glucose control to decrease the risk for GP aggravation. Acute hyperglycemia has been shown to delay GE in patients with diabetes.
Diagnosis for Gastroparesis
For patients with upper gastrointestinal (GI) GP, scintigraphic gastric emptying (SGE) should be the standard diagnostic test. SGE consists of 48-hour cessation of opioids, cannabinoids, prokinetics, antiemetics, and neuromodulators followed by monitoring of GI emptying for 3 hours after the consumption of a 255-kcal, 2% fat Egg Beaters solid meal. The ACG cautions that 37% to 42% of patients can be confounded as having functional dyspepsia and may require repeated SGE evaluations.
An alternative diagnostic strategy can be the use of wireless motility capsule (WMC) testing. Both SGE and WMC have a high degree of agreement (75.7%), and among patients without diabetes, WMC had a higher detection rate of delayed GE than SGE (33.3% vs 17.1%; P <.001). The opposite was observed among patients with diabetes (17.1% vs 41.7%; P =.002). Another alternative diagnostic tool is stable isotope (13C-spirulina) breath test, which has a sensitivity of 93% to identify accelerated GE and 89% for identifying delayed GE.
Radiopaque marker testing is not recommended for GP.
Treatment for Gastroparesis
To manage GP, the ACG recommends a small particle diet. Oral intake is associated with reduced morbidity and mortality risk, and a small particle diet has been associated with symptom relief and improved glycemic control.
The only approved medication for GP by the United States Food and Drug Administration is metoclopramide, which has a boxed warning due to adverse effects and has restrictions about long-term use. Although not specifically approved for GP, evidence supports the use of 5-HT4 agonists to improve GE and metoclopramide to manage refractory symptoms compared with no treatment. Evidence also supports the use of domperidone for symptom management.
In addition, antiemetic agents have been associated with improved symptom control, but they do not improve GE; the ACG does not recommend using central neuromodulators, ghrelin agonists, or haloperidol to manage GP.
Nonpharmacological options for GP include GES and acupuncture for patients with diabetes. Herbal remedies are not recommended.
For patients who are refractory to medical therapy, current evidence supports pyloromyotomy over no intervention. Another pyloric-directed therapeutic option is gastric per-oral endoscopic myotomy (G-POEM), which has been shown to provide symptom relief at 6 months compared with sham control.
The guideline authors concluded, “This guideline has focused on the diagnosis and treatment of GP in adults. […] In particular, the following have potential future impact on the management of GP: The diagnostic value of WMC for GP and for measurements of pan-GI transit and pressure profiles and autonomic nervous system dysfunction are under investigation.”