Refractory Gastroparesis: Expert Recommendations

Gastroparesis is a vexing problem and often has overlapping symptoms with functional dyspepsia. In this update from the American Gastroenterological Association, medically refractory gastroparesis is defined as ongoing symptoms in patients with a confirmed diagnosis of gastroparesis despite appropriate dietary changes and the use of metoclopramide as a first-line therapeutic agent. Algorithms for the diagnosis and management of refractory gastroparesis have not been standardized due to a lack of prospective studies to determine the best approach for these patients. The authors of this clinical practice update used published data and expert review to outline a strategy to define, diagnose, and manage refractory gastroparesis. 

Best practice advice:

• Exclude disorders that can be confused for medically refractory gastroparesis, including mechanical obstruction, hypothyroidism, adrenal insufficiency, and functional dyspepsia.  
• Confirm that the diagnosis is made when the patient is no longer using opioids to manage pain and when the appropriate 4-hour gastric emptying test is employed.
• Classify patients with gastroparesis based on symptoms and results of a gastric emptying study: mild (10%-15% retention at 4 hours), moderate (15%-35%), or severe (>35%).
• Identify the predominant symptom (nausea and/or vomiting vs abdominal pain and/or discomfort), and initiate treatment accordingly. 
• Antiemetics and prokinetics are options for treating nausea and vomiting.
• Neuromodulators should be tried for patients with abdominal pain, whereas opioids should be avoided. 
• Consider gastric electrical stimulation in patients with refractory nausea and vomiting who have failed other therapies; it is not recommended in patients with pain-predominant gastroparesis.
• Consider gastric peroral endoscopic myotomy in a multidisciplinary center for patients with gastroparesis who have severely delayed gastric emptying.