What is the workup and treatment for Gastroparesis (Gastrointestinal Motility Disorder)?

From the Guidelines

Gastroparesis workup should begin with a thorough history and physical examination, followed by diagnostic tests to confirm delayed gastric emptying, and treatment should follow a stepwise approach starting with dietary modifications and medications such as metoclopramide or domperidone, as recommended by the most recent guidelines 1.

Diagnostic Approach

The diagnostic approach to gastroparesis includes:

• Upper endoscopy to rule out mechanical obstruction
• 4-hour gastric emptying scintigraphy, which is the gold standard for diagnosis
• Additional tests may include wireless motility capsule, antroduodenal manometry, or breath testing

Treatment Approach

The treatment approach to gastroparesis includes:

• Dietary modifications:
  • Small, frequent, low-fat, low-fiber meals
  • Adequate hydration
• Medications:
  • Prokinetics: metoclopramide (10mg orally 30 minutes before meals and at bedtime) for up to 12 weeks due to risk of tardive dyskinesia, or domperidone (10-20mg orally 3-4 times daily) which requires FDA special access
  • Antiemetics: ondansetron (4-8mg orally every 8 hours as needed) or prochlorperazine (5-10mg orally every 6 hours)
• For refractory cases:
  • Pyloric botulinum toxin injection
  • Gastric electrical stimulation
  • Surgical interventions like pyloroplasty
• Nutritional support with enteral feeding may be necessary in severe cases
• Addressing underlying causes like diabetes (target HbA1c <7%) is essential, as hyperglycemia can worsen gastric emptying
• Regular monitoring of symptoms, nutritional status, and medication efficacy is important for optimal management of this chronic condition, as supported by recent studies 1.

From the FDA Drug Label

For the Relief of Symptoms Associated with Diabetic Gastroparesis (Diabetic Gastric Stasis) If only the earliest manifestations of diabetic gastric stasis are present, oral administration of metoclopramide may be initiated. However, if severe symptoms are present, therapy should begin with metoclopramide injection (IM or IV)

The treatment for gastroparesis includes:

• Oral metoclopramide for early manifestations of diabetic gastric stasis
• Metoclopramide injection (IM or IV) for severe symptoms Key considerations:
• Dose and administration: 10 mg doses may be administered slowly by the intravenous route over a 1 to 2 minute period
• Duration of treatment: Administration of Metoclopramide Injection, USP up to 10 days may be required before symptoms subside, at which time oral administration of metoclopramide may be instituted 2
• Contraindications: Metoclopramide is contraindicated in patients with stomach or intestine problems, adrenal gland tumor, or allergy to metoclopramide 2
• Special precautions: Use with caution in patients with hypertension, cirrhosis, or congestive heart failure, as metoclopramide may cause fluid retention and volume overload 2

From the Research

Gastroparesis Workup

• The diagnosis of gastroparesis is based on the recognition of clinical symptoms and documentation of delayed gastric emptying 3
• Symptoms of gastroparesis include nausea, vomiting, early satiety, postprandial fullness, bloating, and upper abdominal pain 4, 3
• A confirmed diagnosis of gastroparesis requires measurement of delayed gastric emptying via an appropriate test, such as gastric scintigraphy or breath testing 3

Treatment of Gastroparesis

• The management of gastroparesis involves correcting fluid, electrolyte, and nutritional deficiencies; identifying and treating the cause of delayed gastric emptying; and suppressing or eliminating symptoms with pharmacological agents as first-line therapies 4, 5, 3
• Dietary modifications, such as decreasing solid food component and increasing liquid nutrient component of meals, can help control symptoms 5
• Low viscosity soluble fibers and high-fat liquid meals can be tolerated by patients with mild to moderate gastroparesis symptoms and can be used to supplement their diets 6
• Metoclopramide is the first prokinetic agent of choice, but long-term use should be avoided in certain patient populations due to the risk of tardive dyskinesia 6, 4, 5
• Other treatment options include antiemetic agents, gastric electrical stimulation, and enteral nutrition via jejunostomy tube 4, 5, 7

Medical Management

• Prokinetic agents, such as metoclopramide and domperidone, are the cornerstone in the treatment of gastroparesis 7
• Antiemetic agents, such as promethazine and ondansetron, can be used to reduce nausea and vomiting 7
• Combinations of prokinetic and antiemetic agents are often tried in patients with persistent symptoms 5
• Drug-drug interactions should be considered when co-administering multiple pharmacological agents, as they can lead to undesired clinical outcomes 7