From the Guidelines
Delayed gastric emptying, also known as gastroparesis, should be managed with a multidisciplinary approach, including dietary modifications, medications, and procedures like gastric peroral endoscopic myotomy (G-POEM) for severe cases, as suggested by the most recent study 1. When managing delayed gastric emptying, it's crucial to identify and address the underlying cause, which can include diabetes, post-surgical complications, certain medications, or idiopathic reasons. The condition is characterized by the stomach taking longer than normal to empty its contents into the small intestine, leading to symptoms like nausea, vomiting, and abdominal pain. Some key points to consider in managing delayed gastric emptying include:
- Dietary modifications: Patients should eat smaller, more frequent meals that are low in fat and fiber to ease digestion.
- Medications: Prokinetics like metoclopramide or domperidone can stimulate stomach contractions, while antiemetics like ondansetron can help control nausea and vomiting.
- Avoiding exacerbating factors: Patients should avoid alcohol, smoking, and medications that delay gastric emptying, such as opioids and anticholinergics.
- Considering G-POEM: For patients with severe gastroparesis who have failed other therapies, G-POEM may be an effective option, especially for those with solid-phase gastric retention of >20% at 4 hours and moderate-to-severe symptoms, as indicated by a high Gastroparesis Cardinal Symptom Index (GCSI) total score 1. The decision to offer G-POEM should be based on the full clinical picture, considering factors like the patient's symptoms, gastric emptying scan results, and response to previous treatments, as emphasized in the recent study 1.
From the Research
Delayed Gastric Emptying
Delayed gastric emptying, also known as gastroparesis, is a common cause of chronic nausea and vomiting in gastroenterology practice 2. The symptoms of gastroparesis may include:
- Nausea and vomiting
- Early satiety
- Postprandial fullness
- Abdominal pain
- Bloating
- Upper abdominal pain
Causes of Gastroparesis
The most common forms of gastroparesis are:
- Diabetic
- Postsurgical
- Idiopathic Other causes of gastroparesis include collagen vascular disorders, previous viral illness, and opiate use 3, 4.
Diagnosis of Gastroparesis
The diagnosis of gastroparesis is best determined using a radioisotope-labeled solid meal with scintigraphic imaging for at least 2 hours, and preferably 4 hours, postprandially 2. The test measures the percentage of retention at 4 hours, which can be categorized as:
- Mild (10-19% retention)
- Moderate (20-29% retention)
- Severe (≥30% retention) 4.
Treatment of Gastroparesis
The aims of treatment should be to control symptoms and maintain adequate nutrition and hydration 2. Treatment options include:
- Dietary adjustments, such as eating small meals and limiting fat and fiber intake
- Prokinetic medications, such as metoclopramide, domperidone, and erythromycin
- Antiemetic medications, such as prochlorperazine and ondansetron
- Gastric electrical stimulation (GES)
- Intrapyloric botulinum toxin injection
- Venting gastrostomy or feeding jejunostomy
- Partial gastrectomy and pyloroplasty (rarely used) 2, 5, 3, 6.
Severity of Delayed Gastric Emptying
The severity of delayed gastric emptying can affect patient characteristics, treatment responsiveness, and medication adverse events 4. Severe delay in gastric emptying is a risk factor for increased hospitalizations and ED visits, and opiate use correlates with increased severity of gastric emptying 4.