From the Guidelines
Gastroparesis with significant gastric distention requires prompt management through a combination of dietary modifications, medications, and possibly procedural interventions, with the goal of reducing morbidity, mortality, and improving quality of life. The most recent and highest quality study, 1, published in 2024, suggests that treatment for diabetic gastroparesis may be very challenging, and a low-fiber, low-fat eating plan provided in small frequent meals with a greater proportion of liquid calories may be useful.
- Key considerations in managing gastroparesis include:
- Dietary modifications: small, frequent, low-fat, low-fiber meals, and avoiding carbonated beverages to reduce gastric volume
- Medications:
- Metoclopramide 10mg orally 30 minutes before meals and at bedtime for 4-12 weeks (with monitoring for extrapyramidal side effects)
- Domperidone 10mg orally three times daily (where available)
- Erythromycin 250mg orally three times daily before meals for short-term use
- Procedural interventions:
- Placement of a nasogastric tube for decompression in severe cases
- Antiemetics such as ondansetron 4-8mg orally every 8 hours to manage associated nausea
- Pyloric botulinum toxin injections or gastric electrical stimulation for refractory cases
- Addressing the underlying cause is crucial, whether it's diabetic control, medication adjustment, or treatment of other conditions, as gastroparesis can lead to complications like bezoar formation, malnutrition, or electrolyte disturbances if left untreated, as noted in 1 and 1.
- The use of gastric electrical stimulation using a surgically implantable device has received approval from the FDA, although its efficacy is variable and use is limited to individuals with severe symptoms that are refractory to other treatments, as mentioned in 1 and 1.
- It is essential to weigh the benefits and risks of each treatment option, considering the potential for serious adverse effects, such as those associated with metoclopramide, and to prioritize the patient's quality of life and overall well-being, as emphasized in 1.
From the Research
Significant Gastric Distention-Gastroparesis
- Gastroparesis is a disorder of gastric emptying that occurs in the absence of mechanical obstruction, characterized by symptoms such as nausea, vomiting, bloating, early satiety, and discomfort 2.
- The majority of cases are idiopathic, while long-standing diabetes mellitus is responsible for about 25-30% of cases 2.
- Diabetic gastroparesis can render glucose control extremely difficult, and its treatment represents a major challenge 2.
Treatment Options
- Treatment options for gastroparesis include prokinetic agents (erythromycin, domperidone, metoclopramide) and antiemetics (phenothiazines, serotonin antagonists, butyrophenones) 2.
- Novel agents, such as 5-HT4 serotonin receptor agonists and dopamine D2 receptor antagonists, are also being developed 2.
- Gastric electric stimulation appears to be one of the most effective options, with both low and high-frequency stimulation alleviating symptoms 2.
- Gastrostomy/jejunostomy and other surgical interventions are considered as a "last resort" 2.
Management of Gastroparesis
- Management of gastroparesis should include assessment and correction of nutritional state, relief of symptoms, improvement of gastric emptying, and optimization of glycemic control in diabetics 3.
- Patient nutritional state should be managed by oral dietary modifications, and enteral nutrition via jejunostomy tube should be considered if oral intake is not adequate 3.
- Medical treatment entails the use of prokinetic and antiemetic therapies, with current approved treatment options including metoclopramide and gastric electrical stimulation (GES) 3.
Pathophysiology and Pharmacotherapy
- Gastroparesis is characterized by delayed gastric emptying in the absence of mechanical outlet obstruction, with idiopathic, diabetic, and postsurgical causes being the most common aetiologies 4.
- The condition commonly manifests as upper gastrointestinal symptoms, including nausea, vomiting, postprandial fullness, early satiety, abdominal pain, and bloating 4.
- Strategies for the management of gastroparesis include correction of malnutrition, dehydration, and electrolyte imbalance, relief of symptoms by appropriate use of prokinetic and antiemetic agents, and optimization of glycemic control in patients with diabetes 4.
Pharmacologic Treatments
- Gastroparesis is a neurogastrointestinal disorder of motility, with symptoms resulting from diverse pathophysiological mechanisms, including antroduodenal hypomotility, pylorospasm, increased gastric accommodation, and visceral hypersensitivity 5.
- The most common etiologies of gastroparesis are idiopathic, diabetic, and postsurgical, with less frequent causes including neurodegenerative disorders, myopathies, medication-induced, and paraneoplastic syndrome 5.
- The only Food and Drug Administration-approved medication for gastroparesis is metoclopramide, with other pharmacologic agents targeting the pylorus and effects of neuromodulators also being used 5.
Recent Advances
- Recent studies have significantly advanced our understanding of gastroparesis, with mechanistic studies from diabetic animal models and human full-thickness biopsies highlighting the importance of innate immune dysregulation and injury to the interstitial cells of Cajal and other components of the enteric nervous system 6.
- Newer treatment strategies, including antiemetics (aprepitant), prokinetics (prucalopride, relamorelin), and fundic relaxants (acotiamide, buspirone), are being developed, with endoscopic pyloromyotomy appearing promising over the short term 6.