Treatment Options for Gastroparesis
The cornerstone of gastroparesis management is a stepwise approach beginning with dietary modifications and metoclopramide as first-line pharmacological therapy, followed by alternative medications, and advanced interventions for refractory cases. 1
Diagnosis Confirmation
- Diagnose using gastric emptying scintigraphy (gold standard) with >10% retention at 4 hours
- Rule out mechanical obstruction with endoscopy or barium studies
Non-Pharmacological Management
Dietary Modifications
- Low-fiber, low-fat diet with small, frequent meals (5-6 per day) 1
- Increase proportion of liquid calories and foods with small particle size
- Stepwise nutritional approach:
- Modified solid foods
- Blended/pureed foods
- Liquid diet with oral nutritional supplements
- Enteral nutrition via jejunostomy tube for severe cases
Medication Adjustments
- Withdraw medications that delay gastric emptying:
- GLP-1 receptor agonists
- Pramlintide
- Opioids
- Anticholinergics
- Tricyclic antidepressants (at higher doses)
Pharmacological Management
First-Line Prokinetic Therapy
Alternative Prokinetic Therapy
- Erythromycin 40-250 mg orally 3 times daily 1
- Effectiveness diminishes over time due to tachyphylaxis
Antiemetic Agents for Symptom Control
- Phenothiazines
- Trimethobenzamide
- Serotonin (5-HT3) receptor antagonists
- NK-1 receptor antagonists
- Tricyclic antidepressants (at lower doses)
- SNRIs
- Anticonvulsants
Glycemic Control for Diabetic Gastroparesis
- Achieve near-normal glycemic control to prevent progression
- Adjust insulin timing and dosage to account for delayed gastric emptying
- Consider DPP-4 inhibitors which have a neutral effect on gastric emptying 1
Advanced Interventions for Refractory Cases
Gastric Electrical Stimulation (GES)
- FDA-approved for treating refractory gastroparesis 1, 3
- Most effective for patients with:
- Predominant symptoms of nausea and vomiting
- Diabetic or idiopathic gastroparesis
- Not dependent on opioid medications
- Contraindications:
- Predominant abdominal pain
- Current opioid use
- Very prolonged, intractable symptoms
Other Interventions
- Gastric peroral endoscopic myotomy (G-POEM) for severe delay in gastric emptying 1
- Enteral nutrition via jejunostomy tube when oral intake is inadequate 1, 3
- Botulinum toxin injection into the pylorus (limited evidence) 1, 3
- Partial gastrectomy and pyloroplasty (rarely used, only in carefully selected patients) 3
Common Pitfalls and Caveats
- Failure to confirm diagnosis with objective testing before initiating treatment
- Continuing medications that delay gastric emptying
- Exceeding the 12-week limit for metoclopramide therapy, increasing risk of tardive dyskinesia
- Relying solely on prokinetics without addressing dietary modifications
- Not adjusting therapy based on predominant symptoms
- Inadequate glycemic control in diabetic patients
- Premature escalation to surgical interventions before optimizing medical therapy
Treatment Algorithm
Initial Management:
- Dietary modifications + metoclopramide (10 mg before meals and bedtime)
- For diabetics: optimize glycemic control
If Inadequate Response:
- Switch to or add erythromycin
- Add appropriate antiemetic based on symptom profile
For Refractory Cases:
- Consider nutritional support (enteral feeding via jejunostomy)
- Evaluate for gastric electrical stimulation if predominant nausea/vomiting
- Consider G-POEM for severe gastric emptying delay
The management of gastroparesis requires a structured approach with careful consideration of the patient's specific symptoms, severity of delayed gastric emptying, and underlying etiology to achieve optimal outcomes in terms of morbidity, mortality, and quality of life 1, 3, 4.