What are the symptoms and management of gastroparesis?

Gastroparesis: Symptoms and Management

Gastroparesis is characterized by delayed gastric emptying in the absence of mechanical obstruction, with primary symptoms including nausea, vomiting, early satiety, postprandial fullness, bloating, abdominal pain, and weight loss. 1, 2

Symptoms

Cardinal Symptoms

• Nausea and vomiting - Often the predominant symptoms
• Early satiety - Feeling full after eating small amounts
• Postprandial fullness - Uncomfortable fullness after meals
• Bloating - Abdominal distension sensation
• Epigastric pain/discomfort - Upper abdominal pain
• Weight loss - Due to reduced intake and malnutrition

Severity Classification

Symptoms can range from mild to severe, with severity often correlating with the degree of gastric emptying delay:

• Mild: 10-15% retention at 4 hours
• Moderate: 15-35% retention at 4 hours
• Severe: >35% retention at 4 hours 2

Diagnosis

Diagnosis requires:

1. Presence of characteristic symptoms
2. Documented delayed gastric emptying
3. Absence of mechanical obstruction 1, 2

The gold standard diagnostic test is a 4-hour gastric emptying scintigraphy with imaging at 0,1,2, and 4 hours using a radiolabeled solid meal 2.

Management Algorithm

1. Dietary Modifications (First-Line)

• Small, frequent meals (6 small meals instead of 3 large ones)
• Low-fat, low-fiber content
• Replace solids with liquids when symptoms are severe
• Small particle size diet 1, 2

2. Pharmacological Treatment Based on Predominant Symptom

For Nausea/Vomiting Predominant:

1. Prokinetics:

   • Metoclopramide (10 mg three times daily before meals) - FDA-approved for gastroparesis
     • Monitor for extrapyramidal side effects (tardive dyskinesia)
     • Recommended trial: minimum 4 weeks 1, 3
   • Consider dose reduction in renal impairment (CrCl <40 mL/min) 3

2. Antiemetics:

   • Phenothiazines
   • 5-HT3 receptor antagonists 2

For Pain/Discomfort Predominant:

• Neuromodulators (tricyclic antidepressants at low doses)
• Avoid opioids as they worsen gastric emptying 1, 2

3. Management Based on Severity

Mild Gastroparesis (10-15% retention):

• Dietary modifications
• Antiemetics as needed 2

Moderate Gastroparesis (15-35% retention):

• Dietary modifications
• Antiemetics
• Prokinetics
• Consider cognitive behavioral therapy 2

Severe/Refractory Gastroparesis (>35% retention):

• All above measures
• Consider:
  • Gastric electrical stimulation for refractory nausea/vomiting
  • Pylorus-directed therapies (G-POEM)
  • Nutritional support via jejunostomy tube 1, 2

Important Considerations

Glycemic Control in Diabetic Gastroparesis

• Hyperglycemia can worsen gastric emptying
• Optimize glucose control in diabetic patients 2

Medication Adjustments

• Discontinue medications that delay gastric emptying:
  • Opioids
  • GLP-1 agonists
  • Anticholinergics 1, 2

Avoid Common Pitfalls

1. Not discontinuing interfering medications before diagnostic testing
2. Using inadequate gastric emptying protocols (less than 4 hours)
3. Treating based on symptoms alone without confirming delayed gastric emptying
4. Prescribing opioids for abdominal pain in gastroparesis
5. Overlooking nutritional status in severe cases 1, 2

Special Populations

Elderly Patients

• Use lowest effective dose of metoclopramide
• Higher risk of parkinsonian-like side effects 3

Renal Impairment

• Start metoclopramide at approximately half the recommended dose in patients with CrCl <40 mL/min 3

Gastroparesis management requires a systematic approach focusing on symptom control and maintaining adequate nutrition. Treatment should be tailored based on symptom predominance and severity of gastric emptying delay, with the goal of improving quality of life and preventing complications.