Gastroparesis for the nongastroenterologist

Jorge Araujo-Duran; Arjun Chatterjee; Samita Garg

doi:10.3949/ccjm.91a.23078

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TABLE 1

Medications to discontinue 48 to 72 hours before gastric emptying scintigraphy

Prokinetics
Metoclopramide, cisapride, domperidone, erythromycin

Anticholinergics, antispasmodics
Dicyclomine, donnatal, hyoscyamine, glycopyrrolate

Opioids
Meperidine, codeine, morphine, oxycodone

Laxatives
Any laxative (discontinue 24 hours before)

Gastric acid suppressants, aluminum-containing antacids
Aluminum hydroxide

Calcium channel blockers
Amlodipine, nifedipine

Agents that may affect gastric emptying
Atropine, benzodiazepines, octreotide, progesterone, theophylline, phenylamine

Adapted from reference 25.

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TABLE 2

Differential diagnosis of gastroparesis

Disorder	Clinical presentation and differentiation from gastroparesis	Treatment
Functional dyspepsia	Less nausea and vomiting Often indistinguishable	Helicobacter pylori eradication, proton pump inhibitors, tricyclic antidepressants, prokinetics, consider psychotherapy²⁹
Rumination syndrome	Effortless and repetitive regurgitation of ingested food	Behavioral modification: deep-breathing exercises, diaphragmatic breathing
Cyclic vomiting syndrome	Absence of symptoms between vomiting episodes Compulsive hot bathing or showering Strong association with personal or family history of migraines	Acute attacks: ondansetron, triptans, aprepitant Prophylaxis: tricyclic antidepressant, topiramate, aprepitant, zonisamide, levetiracetam
Cannabinoid hyperemesis syndrome	Absence of symptoms between vomiting episodes Compulsive hot bathing or showering Cannabis use Gastric emptying scintigraphy might be normal	Benzodiazepines, tricyclic antidepressants, haloperidol, droperidol, promethazine, prochlorperazine, ondansetron, corticosteroids, capsaicin Cannabis cessation
Anorexia or bulimia	Binge and purge behavior (bulimia), and severe caloric restriction (anorexia)	Psychotherapy, selective serotonin reuptake inhibitors
Anxiety disorder toward food (avoidant restrictive food intake disorder)	Immediate postprandial nausea and vomiting when patients see the food or put it in their mouth	Cognitive behavioral therapy, cyproheptadine
Narcotic bowel syndrome	Chronic or intermittent colicky abdominal pain that worsens when the narcotic effect wears off Constipation is common	Clonidine, benzodiazepines, tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, laxatives, methylnaltrexone

Based on information from references 30–32.

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TABLE 3

Management strategies for gastroparesis

Exclude iatrogenic causes (eg, opioids, surgery, glucagon-like peptide 1 receptor agonists)
Diet modification Small-particle diet to improve symptom relief and facilitate gastric emptying
Pharmacologic therapy
	Dosage	Side effects
Prokinetics
Metoclopramide^a	10 mg 3 times a day, 30 minutes before meals, for a maximum of 3 months, or 70-μL spray 30 minutes before meals and at bedtime for 2–8 weeks	Extrapyramidal symptoms (1%–25%, higher in elderly and young), tardive dyskinesia (around 0.1% per 1,000 patient-years)
Erythromycin	250 mg 3 times a day for 1 to 2 weeks	Tachyphylaxis after 4 weeks
Domperidone^b	10 mg 3 times a day	QTc interval prolongation (6%)
Antiemetics
5-HT3 receptor antagonists (granisetron, ondansetron)	Same dosage as that used to manage nausea or emesis, or as needed per patient	QTc interval prolongation, second-degree heart block (< 1%)
Neurokinin antagonists (aprepitant, tradipitant)	Aprepitant dose tested in clinical trials is 125 mg once daily	Fatigue, constipation (> 10%)
Neuromodulators
Levosulpiride	Start with minimum effective dose	Sedation, hypotension, dyskinesia
Buspirone	Start with minimum effective dose	Dizziness, drowsiness
Mirtazapine	Start with minimum effective dose	Somnolence, xerostomia, weight gain
Haloperidol	Start with minimum effective dose	Extrapyramidal symptoms

Nonpharmacologic therapies Gastric electrical stimulation (“gastric pacemaker”), acupuncture
Pyloric interventions
Endoscopic functional luminal imaging probe	Used to evaluate pyloric function and predict treatment outcomes following gastric peroral endoscopic myotomy
Intrapyloric injection of botulinum toxin	Not recommended
Laparoscopic (Heineke-Mikulicz) pyloroplasty	Safe and enhances gastric emptying with short-term improvement in symptoms
Gastric peroral endoscopic myotomy	Improves gastric emptying and is equivalent to laparoscopic pyloroplasty

↵^aOnly medication approved by US Food and Drug Administration (FDA) for gastroparesis; nasal spray is FDA-approved for diabetic gastroparesis.
↵^bAvailable through the FDA’s program for expanded access to investigational drugs.