ACG clinical guideline: gastroparesis

Key points

• Gastroparesis means symptoms suggesting food retention with objectively delayed gastric emptying and no mechanical obstruction; this ACG guideline updates the 2013 version using GRADE and expert key concepts.
• Scintigraphic gastric emptying of a solid meal over 3 hours or longer is the standard test (strong recommendation, moderate evidence); a wireless motility capsule or a 13C-spirulina breath test are alternatives, while radiopaque markers are not suggested.
• Management includes a small particle diet and, in diabetic gastroparesis, optimal glucose control.
• Metoclopramide is suggested over no treatment for refractory symptoms, domperidone where it is approved, and 5-HT4 agonists to improve gastric emptying; antiemetics help symptoms but do not improve emptying (all conditional recommendations, low quality evidence).
• For symptoms refractory to medical therapy, pyloromyotomy is suggested over no treatment, and gastric electrical stimulation may be considered as a humanitarian use device.

Overview

Gastroparesis presents with postprandial fullness, nausea, vomiting and upper abdominal pain, carries a substantial burden and is associated with increased morbidity and mortality. Mechanical obstruction should be excluded by endoscopy or radiology. In the United States there are no FDA-approved therapies other than metoclopramide, whose prescription is limited to 3 months.

Not recommended

Central neuromodulators and ghrelin agonists are not recommended (strong recommendations, moderate evidence), and current data do not support haloperidol. Herbal therapies such as Rikkunshito or STW5 (Iberogast) should not be recommended. Acupuncture, alone or with prokinetics, may help in diabetic gastroparesis but not in other causes. Pain in gastroparesis should not be treated with opioids, including tramadol and tapentadol, which slow transit and gastric emptying.

Pyloric interventions

EndoFLIP evaluation may help characterise pyloric function and predict outcomes after peroral pyloromyotomy. Intrapyloric botulinum toxin is not recommended based on randomised trials. Open-label studies of gastric peroral endoscopic myotomy (G-POEM) show symptom improvement and better emptying, mostly over 3-6 months; in a 12-month study 56% of patients improved at 1 year, and endoscopic myotomy has fewer complications and shorter hospital stay than surgical myotomy.

FAQ

How is gastroparesis diagnosed?

By documenting delayed gastric emptying of a solid meal, usually with scintigraphy over at least 3 hours, after excluding mechanical obstruction with endoscopy or imaging.

Which medicines are suggested?

Metoclopramide for refractory symptoms, domperidone where approved, 5-HT4 agonists to improve emptying, and antiemetics for symptom control.

What if medicines do not work?

Pyloromyotomy is suggested over no treatment for refractory symptoms, and gastric electrical stimulation may be considered.

Source

Camilleri M, Kuo B, Nguyen L, et al. ACG Clinical Guideline: Gastroparesis. Am J Gastroenterol 2022;117(8):1197-1220. DOI: 10.14309/ajg.0000000000001874. HHS Public Access author manuscript, available in PMC. Summary prepared by Medpresso from the original publication; it is not a substitute for the full text or for medical advice.