What is the management of gastroparesis?

Management of Gastroparesis

The management of gastroparesis should follow a stepwise approach starting with dietary modifications and prokinetic medications, followed by antiemetic agents for symptom control, and progressing to more invasive interventions only for refractory cases. 1

Initial Assessment and Diagnosis

• Confirm diagnosis with gastric emptying scintigraphy (>10% retention at 4 hours)
• Rule out mechanical obstruction with endoscopy or barium studies
• Identify the underlying cause (diabetic, post-surgical, medication-induced, post-viral, idiopathic)
• Assess dominant symptoms (nausea, vomiting, early satiety, abdominal pain) to guide treatment

First-Line Management

Dietary Modifications

• Implement low-fiber, low-fat diet with small, frequent meals (5-6 per day)
• Increase proportion of liquid calories and foods with small particle size
• Follow stepwise nutritional approach:
  • Start with modified solid foods
  • Progress to blended/pureed foods if needed
  • Consider liquid diet with oral nutritional supplements for severe cases

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 neutral effect on gastric emptying

Pharmacological Treatment

Prokinetic Agents

• Metoclopramide: 10 mg orally, 30 minutes before meals and at bedtime

  • First-line prokinetic therapy
  • Limited to 12 weeks due to risk of tardive dyskinesia
  • Reduce dose by 50% in patients with creatinine clearance <40 mL/min 2
  • Monitor for extrapyramidal symptoms, especially in elderly and pediatric patients

• Erythromycin: 40-250 mg orally 3 times daily

  • Alternative prokinetic therapy
  • Effectiveness diminishes over time due to tachyphylaxis

Antiemetic Agents

• 5-HT3 receptor antagonists (ondansetron, granisetron)
• NK-1 receptor antagonists (aprepitant)
• Phenothiazines
• Trimethobenzamide
• Tricyclic antidepressants
• SNRIs
• Anticonvulsants

Second-Line Management (For Refractory Cases)

Advanced Nutritional Support

• Enteral nutrition via jejunostomy tube when oral intake is inadequate

  • Endoscopic/surgical transjejunal tube or combined gastrojejunostomy tube
  • Placed beyond the pylorus
  • Can improve weight recovery with acceptable morbidity and mortality
  • May be removed after average of 20 months

• Parenteral nutrition only in cases of severe nutritional compromise

  • Used as a bridge to other therapies

Endoscopic Interventions

• Gastric per oral endoscopic myotomy (G-POEM)

  • Not considered first-line therapy
  • Should only be performed at tertiary care centers by experts
  • May improve symptoms and reduce gastric emptying times
  • Risk of dumping syndrome
  • Lacks randomized, sham-controlled studies

• Intrapyloric botulinum toxin injection

  • Not recommended based on placebo-controlled studies showing no benefit
  • May be considered in clinical trials only

• Transpyloric stent placement

  • Considered investigational
  • Concerns over stent migration
  • Lacks data from prospective, sham-controlled trials

Surgical Interventions

• Gastric electrical stimulation (GES)

  • FDA-approved for treating refractory gastroparesis
  • Improves nausea and vomiting symptoms
  • Indicated for patients who have failed standard therapy
  • Not effective for patients with predominant abdominal pain
  • Contraindicated in current opioid users

• Laparoscopic pyloroplasty or sleeve gastrectomy

  • Unclear role due to absence of large, well-designed trials

• Partial or total gastrectomy

  • Rarely required
  • Carries risk of dumping syndrome
  • Consider only after all available therapies exhausted
  • Should be performed at tertiary care centers

Common Pitfalls and Caveats

1. Overreliance on gastric emptying studies: Pursuing invasive options based on a single gastric emptying study without clinical context may lead to inappropriate management.

2. Inadequate trial of medical therapy: Ensure adequate dosing and duration of prokinetic and antiemetic medications before escalating to invasive interventions.

3. Neglecting nutritional status: Monitor and address nutritional deficiencies throughout treatment.

4. Metoclopramide safety concerns: Limit use to 12 weeks due to risk of tardive dyskinesia; monitor closely for neurological side effects.

5. Inappropriate patient selection for GES: Not effective for patients with predominant abdominal pain or those dependent on opioids.

6. Overlooking glycemic control in diabetic patients: Poor glycemic control can worsen gastroparesis symptoms.

7. Inadequate symptom-based approach: Treatment should target the dominant symptom (nausea, vomiting, early satiety, pain) rather than using a one-size-fits-all approach.