Gastroparesis

Matthew Miles; Matthew Woo; Yasmin Nasser

doi:10.1503/cmaj.221069

Gastroparesis is more common in women

Gastroparesis is defined by delayed gastric emptying without mechanical obstruction, causing epigastric symptoms.1 Prevalence in the United States is 9.6 cases per 100 000 person-years for men and 37.8 cases per 100 000 person-years for women.2

Consider gastroparesis in patients with chronic nausea and vomiting

Gastroparesis presents with nausea, vomiting and dyspeptic symptoms (e.g., postprandial fullness, early satiety, epigastric pain and bloating).1 The pathophysiology includes impairment in gastric neuromuscular function.2 Risk factors for gastroparesis include diabetes, upper abdominal surgery, neurological diseases (e.g., Parkinson disease), connective tissue diseases and medications that delay gastric emptying (e.g., opioids, anticholinergic medications, glucagon-like peptide-1 receptor agonists [e.g., semaglutide]). 1 Most cases are idiopathic.2 The differential diagnosis includes functional dyspepsia, cyclic vomiting syndrome and rumination syndrome.2

A gastric emptying study is required to diagnose gastroparesis

Patients with suspected gastroparesis should be referred for an upper gastrointestinal endoscopy to exclude an obstruction.1 Evidence of delayed gastric emptying is required to establish the diagnosis.1 The scintigraphic emptying test provides a reliable assessment of gastric emptying; more than 10% meal retention at 4 hours is abnormal.

Treatments include dietary modifications and prokinetic agents

Patients should follow a low-fat, low-fibre diet and eat small, frequent meals to manage symptoms.2 Prokinetic agents, such as first-line dopamine-2 antagonists (e.g., domperidone) or 5-hydroxytryptamine 4 receptor agonists (e.g., prucalopride), should be used.1 Medications that delay gastric emptying should be avoided.3 Therapies can be trialled before endoscopy if the suspicion of gastroparesis is high; they should be held before scintigraphy.

Refer patients with persistent symptoms to gastroenterology

Second-line pharmacological therapies include antiemetics (e.g., 5-hydroxytryptamine 3 receptor antagonists and neurokinin-1 receptor antagonists), prokinetic agents (e.g., macrolide antibiotics) or antidepressants (e.g., tricyclic antidepressants, serotonin–norepinephrine reuptake inhibitors or tetracyclics).4 Enteral nutrition may be required in patients with refractory symptoms.4

Footnotes

Competing interests: Yasmin Nasser reports receiving research support, outside of this work, from Allergan as local principal investigator on a clinical trial. She was a speaker for a webinar on chronic pain in inflammatory bowel disease for AbbVie (2021) and also participated on an advisory board for Allergan (2020), outside of this work. No other competing interests were declared.
This article has been peer reviewed.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/

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