What is the next course of action for a patient with a 14-year history of moderate to severe chronic gastritis, who tested negative for H. pylori, and has not improved with esomeprazole (PPI) and sucralfate, and takes 2 hours to complete a small meal?

Gastroparesis Evaluation and Prokinetic Therapy

This patient's symptom of taking 2 hours to complete a small meal strongly suggests gastroparesis or severe gastric dysmotility, and she requires immediate evaluation with gastric emptying scintigraphy followed by prokinetic therapy if confirmed, as her prolonged meal duration is a cardinal symptom of delayed gastric emptying that will not respond to continued acid suppression alone. 1

Why Current Treatment Has Failed

The patient has received appropriate acid suppression with esomeprazole (Esmo-D) and mucosal protection with sucralfate, but these agents do not address dysmotility. 1

• Sucralfate has no effect on gastric emptying or motility - it works purely through mucosal protection and has been shown ineffective for H. pylori eradication or altering gastritis progression 2, 3, 4
• PPIs like esomeprazole effectively suppress acid but do not improve gastric motility - they are appropriate for ulcer-like dyspepsia but ineffective for dysmotility-like symptoms 1, 5
• The 2-hour meal completion time is a red flag for gastroparesis, not acid-related disease 1

Immediate Diagnostic Steps Required

Order gastric emptying scintigraphy (4-hour solid-phase study) to objectively confirm gastroparesis before initiating prokinetic therapy. 1

• This is the gold standard test for diagnosing delayed gastric emptying 1
• The patient's symptom profile (early satiety, prolonged meal duration) makes this diagnosis highly likely 1
• Do not continue empiric acid suppression without addressing the underlying motility disorder 1

Definitive Treatment Algorithm

If Gastroparesis is Confirmed:

Initiate prokinetic therapy as the primary treatment, as prokinetics are currently the only agents available for dysmotility-like symptoms. 1

• First-line prokinetic options include metoclopramide (start 5-10 mg three times daily, 30 minutes before meals) 1
• Note that cisapride can no longer be recommended due to cardiac toxicity 1
• Continue PPI therapy at the lowest effective dose (esomeprazole 20 mg once daily) to maintain gastritis control, but recognize this is adjunctive, not primary therapy 1, 6

If Gastroparesis is Not Confirmed:

Consider functional dyspepsia with predominant dysmotility-like symptoms and trial prokinetic therapy empirically. 1

• The symptom pattern (fullness, prolonged satiety) indicates dysmotility-like dyspepsia even if gastric emptying is normal 1
• Prokinetics remain appropriate even without documented delayed emptying when dysmotility symptoms predominate 1

Second-Line Options if Prokinetics Fail

Add neuromodulation with low-dose tricyclic antidepressants (amitriptyline 10 mg once daily at bedtime, titrate to 30-50 mg as tolerated). 6

• TCAs are effective second-line treatment for functional dyspepsia refractory to first-line therapy 6
• They work through visceral analgesic and neuromodulatory effects, not acid suppression 6
• Start low and go slow to minimize anticholinergic side effects 6

Critical Management Pitfalls to Avoid

Do not continue indefinite acid suppression without addressing the motility component - this patient has already failed 30 days of PPI therapy because the wrong mechanism is being targeted. 1, 6

• The 14-year history suggests chronic gastritis is stable and H. pylori-negative disease does not require ongoing high-dose PPI 1
• Taper esomeprazole to the lowest effective dose (20 mg once daily or even on-demand therapy) once symptoms improve with prokinetic therapy 1, 6, 7
• Do not repeat endoscopy at this stage unless alarm symptoms develop (weight loss, bleeding, dysphagia) - the next step is therapeutic escalation, not more diagnostic testing 1, 6

Do not dismiss the 2-hour meal completion time as "just dyspepsia" - this specific symptom has high specificity for gastroparesis and requires objective evaluation. 1

Long-Term Management Considerations

Once symptoms improve with prokinetic therapy:

• Reassess PPI necessity - many patients with H. pylori-negative chronic gastritis can be weaned to on-demand therapy 1, 6
• Continue prokinetic therapy long-term if symptoms recur with discontinuation 1
• Regular aerobic exercise is recommended for all patients with functional dyspepsia and may improve gastric emptying 6
• If symptoms remain refractory despite prokinetics and neuromodulation, refer for behavioral therapies (cognitive behavioral therapy, hypnotherapy, diaphragmatic breathing) 1, 6