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Gastroparesis

Definition
GP is a syndrome characterized by delayed gastric emptying and symptoms thereof in the absence of gastric outlet obstruction.
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Pathophysiology
GP is most frequently caused by diabetes mellitus neuropathy and idiopathic causes. Other causes include iatrogenic vagotomy (surgery for peptic ulcer disease, fundoplication), post-infection, CNS diseases (stroke, other causes of autonomic neuropathy, Parkinson's disease, spinal cord injury), paraneoplastic syndrome, polymyositis, scleroderma, drugs (opiates, anticholinergic drugs), metabolic disorders (hypothyroidism, hyperparathyroidism, Addison's disease), lung transplantation, anorexia nervosa, and pregnancy.
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Epidemiology
The incidence of GP in the US women and men is estimated at 9.8 per 100,000 person-years and 2.4 per 100,000 person-years, respectively.
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Disease course
Clinical manifestations include nausea, vomiting, upper abdominal pain or discomfort, early satiety, postprandial fullness, bloating, heartburn, and dysphagia. Severe disease is related to depression, anxiety, increased hospitalizations, medication, or tube feeding decreasing QoL.
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Prognosis and risk of recurrence
GP independently is not associated with increased mortality.
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Key sources
The following summarized guidelines for the evaluation and management of gastroparesis are prepared by our editorial team based on guidelines from the American Gastroenterological Association (AGA 2022), the American College of Gastroenterology (ACG 2022; 2013), the European Society for Neurogastroenterology and Motility (ESNM/UEG 2021), and the European Society of Gastrointestinal Endoscopy (ESGE 2020).
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Guidelines

1.Screening and diagnosis

Clinical presentation: recognize that:
GP refers to a symptom or set of symptoms associated with delayed gastric emptying
A
and severely disturbed gastric motor function in the absence of mechanical obstruction
B
nausea and vomiting are cardinal symptoms of GP
B
dyspeptic symptoms, such as postprandial fullness, early satiation, epigastric pain, as well as bloating in the upper abdomen and belching are often present in GP
B
symptoms in GP overlap mainly with postprandial distress syndrome and less with epigastric pain syndrome symptoms of functional dyspepsia
B
GP is associated with a significant decrease in QoL
A
GP is associated with psychosocial comorbidities, such as anxiety and depression.
A
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  • Diagnosis

  • Differential diagnosis

2.Classification and risk stratification

Risk factors
Recognize that the following conditions are associated with an increased risk for the development of GP:
diabetes
A
partial gastric resection/vagotomy, bariatric surgery, and antireflux surgery
B
certain neurological disorders, such as Parkinson's disease, multiple sclerosis, and amyloid neuropathy
B
certain connective tissue diseases
B
certain drugs, such as opioids.
A
Recognize that the prognosis of GP depends on the cause.
B

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  • Severity assessment

3.Diagnostic investigations

Pre-test preparation
Discontinue medications affecting gastric emptying at least 48 hours before diagnostic testing, or > 48 hours before testing depending on the pharmacokinetics of the medication.
A
Measure blood glucose level in patients with diabetes before gastric emptying testing, and treat hyperglycemia with a test started after blood glucose is < 275 mg/dL.
B

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  • Gastric emptying studies (modalities)

  • Gastric emptying studies (methodology)

  • Functional lumen imaging probe

  • Evaluation for underlying cause

4.Diagnostic procedures

Upper gastrointestinal endoscopy: perform upper gastrointestinal endoscopy to establish a diagnosis of GP.
A

5.Medical management

General principles: as per ACG 2022 guidelines, consider offering pharmacotherapy to improve gastric emptying and GP symptoms in patients with idiopathic and diabetic GP, taking into account the benefits and risks of treatment.
C

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  • Cessation of precipitating medications

  • Glycemic control

  • Prokinetics and antiemetics

  • Neuromodulators

  • Ghrelin agonists

  • Haloperidol

6.Nonpharmacologic interventions

Dietary therapy: as per ACG 2022 guidelines, offer a small particle size diet as dietary management of GP to increase likelihood of symptom relief and enhance gastric emptying.
B

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  • Acupuncture

  • Herbal products

7.Therapeutic procedures

Indications for endoscopic pylorus-directed therapies: consider offering endoscopic pylorus-directed therapies only in patients with symptoms suggestive of GP in combination with objective proof of delayed gastric emptying using a validated test, and only when medical therapy has failed.
B

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  • Intrapyloric injection of botulinum toxin

  • Endoscopic pyloric dilation

  • Endoscopic transpyloric stenting

  • Gastric electrical stimulation

8.Perioperative care

Perioperative antibiotic prophylaxis: administer prophylactic antibiotics during gastric POEM. Adapt the choice and duration of antibiotics according to national or local protocols.
B

9.Surgical interventions

Gastric peroral endoscopic myotomy: as per ACG 2022 guidelines, consider performing pyloromyotomy for symptom control in patients with GP with symptoms refractory to medical therapy.
C