Treatment of gastroparesis
- Michael Camilleri, MD
Michael Camilleri, MD
- Professor of Medicine and Physiology
- Mayo Clinic College of Medicine
Gastroparesis is a syndrome of objectively delayed gastric emptying in the absence of a mechanical obstruction and cardinal symptoms of nausea, vomiting, early satiety, bloating, and/or upper abdominal pain.
This topic will review the treatment of gastroparesis. The pathophysiology, etiology, and diagnosis of gastroparesis and the management of malignancy-associated gastroparesis are discussed separately. (See "Pathogenesis of delayed gastric emptying" and "Gastroparesis: Etiology, clinical manifestations, and diagnosis" and "Malignancy-associated gastroparesis: Pathophysiology and management".)
Our recommendations are largely consistent with the guidelines issued by the American Gastroenterological Association (AGA) and the American College of Gastroenterology (ACG) [1,2].
Initial management of gastroparesis consists of dietary modification, optimization of glycemic control and hydration, and in patients with continued symptoms, pharmacologic therapy with prokinetic and antiemetics. A suggested approach to the management of gastroparesis based on the extent of delay in gastric emptying is outlined in the algorithm (algorithm 1).
Dietary modification — Dietary modification is considered first line therapy in patients with mild gastroparesis, although in clinical practice it is associated with only a modest improvement in symptoms. Fat slows gastric emptying and nondigestible fiber (eg, fresh fruits and vegetables) require effective interdigestive antral motility that is frequently absent in patients with significantly delayed gastric emptying. Patients with gastroparesis should be advised by a dietician to consume small, frequent meals four to five times a day that are low in fat and contain only soluble fiber. For patients who are unable to tolerate solid food, meals should be homogenized, as gastric emptying of liquids is often normal even when emptying of solids is delayed [2,3]. Patients should also be advised to avoid carbonated beverages as they can aggravate gastric distention . Alcohol and smoking should also be avoided as they can decrease antral contractility and delay gastric emptying [4,5].
- Parkman HP, Hasler WL, Fisher RS, American Gastroenterological Association. American Gastroenterological Association technical review on the diagnosis and treatment of gastroparesis. Gastroenterology 2004; 127:1592.
- Camilleri M, Parkman HP, Shafi MA, et al. Clinical guideline: management of gastroparesis. Am J Gastroenterol 2013; 108:18.
- Parkman HP, Yates KP, Hasler WL, et al. Dietary intake and nutritional deficiencies in patients with diabetic or idiopathic gastroparesis. Gastroenterology 2011; 141:486.
- Bujanda L. The effects of alcohol consumption upon the gastrointestinal tract. Am J Gastroenterol 2000; 95:3374.
- Miller G, Palmer KR, Smith B, et al. Smoking delays gastric emptying of solids. Gut 1989; 30:50.
- Ogorek CP, Davidson L, Fisher RS, Krevsky B. Idiopathic gastroparesis is associated with a multiplicity of severe dietary deficiencies. Am J Gastroenterol 1991; 86:423.
- Camilleri M. Appraisal of medium- and long-term treatment of gastroparesis and chronic intestinal dysmotility. Am J Gastroenterol 1994; 89:1769.
- Camilleri M. Clinical practice. Diabetic gastroparesis. N Engl J Med 2007; 356:820.
- Holzäpfel A, Festa A, Stacher-Janotta G, et al. Gastric emptying in Type II (non-insulin-dependent) diabetes mellitus before and after therapy readjustment: no influence of actual blood glucose concentration. Diabetologia 1999; 42:1410.
- Gaber AO, Oxley D, Karas J, et al. Changes in gastric emptying in recipients of successful combined pancreas-kidney transplants. Dig Dis 1991; 9:437.
- Bharucha AE, Camilleri M, Forstrom LA, Zinsmeister AR. Relationship between clinical features and gastric emptying disturbances in diabetes mellitus. Clin Endocrinol (Oxf) 2009; 70:415.
- Fraser R, Horowitz M, Dent J. Hyperglycaemia stimulates pyloric motility in normal subjects. Gut 1991; 32:475.
- Barnett JL, Owyang C. Serum glucose concentration as a modulator of interdigestive gastric motility. Gastroenterology 1988; 94:739.
- Jebbink RJ, Samsom M, Bruijs PP, et al. Hyperglycemia induces abnormalities of gastric myoelectrical activity in patients with type I diabetes mellitus. Gastroenterology 1994; 107:1390.
- Fraser RJ, Horowitz M, Maddox AF, et al. Hyperglycaemia slows gastric emptying in type 1 (insulin-dependent) diabetes mellitus. Diabetologia 1990; 33:675.
- Horowitz M, Maddox AF, Wishart JM, et al. Relationships between oesophageal transit and solid and liquid gastric emptying in diabetes mellitus. Eur J Nucl Med 1991; 18:229.
- Jones KL, Berry M, Kong MF, et al. Hyperglycemia attenuates the gastrokinetic effect of erythromycin and affects the perception of postprandial hunger in normal subjects. Diabetes Care 1999; 22:339.
- Petrakis IE, Kogerakis N, Prokopakis G, et al. Hyperglycemia attenuates erythromycin-induced acceleration of liquid-phase gastric emptying of hypertonic liquids in healthy subjects. Dig Dis Sci 2002; 47:67.
- Petrakis IE, Kogerakis N, Vrachassotakis N, et al. Hyperglycemia attenuates erythromycin-induced acceleration of solid-phase gastric emptying in healthy subjects. Abdom Imaging 2002; 27:309.
- Groop LC, Luzi L, DeFronzo RA, Melander A. Hyperglycaemia and absorption of sulphonylurea drugs. Lancet 1989; 2:129.
- Rao AS, Camilleri M. Review article: metoclopramide and tardive dyskinesia. Aliment Pharmacol Ther 2010; 31:11.
- Bateman DN, Rawlins MD, Simpson JM. Extrapyramidal reactions with metoclopramide. Br Med J (Clin Res Ed) 1985; 291:930.
- Oh JJ, Kim CH. Gastroparesis after a presumed viral illness: clinical and laboratory features and natural history. Mayo Clin Proc 1990; 65:636.
- McCallum RW, Valenzuela G, Polepalle S, Spyker D. Subcutaneous metoclopramide in the treatment of symptomatic gastroparesis: clinical efficacy and pharmacokinetics. J Pharmacol Exp Ther 1991; 258:136.
- Patterson D, Abell T, Rothstein R, et al. A double-blind multicenter comparison of domperidone and metoclopramide in the treatment of diabetic patients with symptoms of gastroparesis. Am J Gastroenterol 1999; 94:1230.
- Silvers D, Kipnes M, Broadstone V, et al. Domperidone in the management of symptoms of diabetic gastroparesis: efficacy, tolerability, and quality-of-life outcomes in a multicenter controlled trial. DOM-USA-5 Study Group. Clin Ther 1998; 20:438.
- Sugumar A, Singh A, Pasricha PJ. A systematic review of the efficacy of domperidone for the treatment of diabetic gastroparesis. Clin Gastroenterol Hepatol 2008; 6:726.
- Drolet B, Rousseau G, Daleau P, et al. Domperidone should not be considered a no-risk alternative to cisapride in the treatment of gastrointestinal motility disorders. Circulation 2000; 102:1883.
- Prather CM, Camilleri M, Thomforde GM, et al. Gastric axial forces in experimentally delayed and accelerated gastric emptying. Am J Physiol 1993; 264:G928.
- Keshavarzian A, Isaac RM. Erythromycin accelerates gastric emptying of indigestible solids and transpyloric migration of the tip of an enteral feeding tube in fasting and fed states. Am J Gastroenterol 1993; 88:193.
- Bruley des Varannes S, Parys V, Ropert A, et al. Erythromycin enhances fasting and postprandial proximal gastric tone in humans. Gastroenterology 1995; 109:32.
- Janssens J, Peeters TL, Vantrappen G, et al. Improvement of gastric emptying in diabetic gastroparesis by erythromycin. Preliminary studies. N Engl J Med 1990; 322:1028.
- Maganti K, Onyemere K, Jones MP. Oral erythromycin and symptomatic relief of gastroparesis: a systematic review. Am J Gastroenterol 2003; 98:259.
- Larson JM, Tavakkoli A, Drane WE, et al. Advantages of azithromycin over erythromycin in improving the gastric emptying half-time in adult patients with gastroparesis. J Neurogastroenterol Motil 2010; 16:407.
- Moshiree B, McDonald R, Hou W, Toskes PP. Comparison of the effect of azithromycin versus erythromycin on antroduodenal pressure profiles of patients with chronic functional gastrointestinal pain and gastroparesis. Dig Dis Sci 2010; 55:675.
- Feldman M, Smith HJ. Effect of cisapride on gastric emptying of indigestible solids in patients with gastroparesis diabeticorum. A comparison with metoclopramide and placebo. Gastroenterology 1987; 92:171.
- Schuurkes J. Effect of cisapride on gastric motility. Z Gastroenterol 1990; 28 Suppl 1:27.
- Wehrmann T, Lembcke B, Caspary WF. Influence of cisapride on antroduodenal motor function in healthy subjects and diabetics with autonomic neuropathy. Aliment Pharmacol Ther 1991; 5:599.
- Jian R, Ducrot F, Ruskone A, et al. Symptomatic, radionuclide and therapeutic assessment of chronic idiopathic dyspepsia. A double-blind placebo-controlled evaluation of cisapride. Dig Dis Sci 1989; 34:657.
- Abell TL, Camilleri M, DiMagno EP, et al. Long-term efficacy of oral cisapride in symptomatic upper gut dysmotility. Dig Dis Sci 1991; 36:616.
- Camilleri M, Balm RK, Zinsmeister AR. Determinants of response to a prokinetic agent in neuropathic chronic intestinal motility disorder. Gastroenterology 1994; 106:916.
- Pitt HA, Mann LL, Berquist WE, et al. Chronic intestinal pseudo-obstruction. Management with total parenteral nutrition and a venting enterostomy. Arch Surg 1985; 120:614.
- Murr MM, Sarr MG, Camilleri M. The surgeon's role in the treatment of chronic intestinal pseudoobstruction. Am J Gastroenterol 1995; 90:2147.
- Warner E, Jeejeebhoy KN. Successful management of chronic intestinal pseudo-obstruction with home parenteral nutrition. JPEN J Parenter Enteral Nutr 1985; 9:173.
- Jones MP, Maganti K. A systematic review of surgical therapy for gastroparesis. Am J Gastroenterol 2003; 98:2122.
- Karlstrom L, Kelly KA. Roux-Y gastrectomy for chronic gastric atony. Am J Surg 1989; 157:44.
- Forstner-Barthell AW, Murr MM, Nitecki S, et al. Near-total completion gastrectomy for severe postvagotomy gastric stasis: analysis of early and long-term results in 62 patients. J Gastrointest Surg 1999; 3:15.
- Hibbard ML, Dunst CM, Swanström LL. Laparoscopic and endoscopic pyloroplasty for gastroparesis results in sustained symptom improvement. J Gastrointest Surg 2011; 15:1513.
- Prakash C, Lustman PJ, Freedland KE, Clouse RE. Tricyclic antidepressants for functional nausea and vomiting: clinical outcome in 37 patients. Dig Dis Sci 1998; 43:1951.
- Sawhney MS, Prakash C, Lustman PJ, Clouse RE. Tricyclic antidepressants for chronic vomiting in diabetic patients. Dig Dis Sci 2007; 52:418.
- Parkman HP, Van Natta ML, Abell TL, et al. Effect of nortriptyline on symptoms of idiopathic gastroparesis: the NORIG randomized clinical trial. JAMA 2013; 310:2640.
- Wang CP, Kao CH, Chen WK, et al. A single-blinded, randomized pilot study evaluating effects of electroacupuncture in diabetic patients with symptoms suggestive of gastroparesis. J Altern Complement Med 2008; 14:833.
- Miller LS, Szych GA, Kantor SB, et al. Treatment of idiopathic gastroparesis with injection of botulinum toxin into the pyloric sphincter muscle. Am J Gastroenterol 2002; 97:1653.
- Woodward MN, Spicer RD. Intrapyloric botulinum toxin injection improves gastric emptying. J Pediatr Gastroenterol Nutr 2003; 37:201.
- Ezzeddine D, Jit R, Katz N, et al. Pyloric injection of botulinum toxin for treatment of diabetic gastroparesis. Gastrointest Endosc 2002; 55:920.
- Lacy BE, Zayat EN, Crowell MD, Schuster MM. Botulinum toxin for the treatment of gastroparesis: a preliminary report. Am J Gastroenterol 2002; 97:1548.
- Bromer MQ, Friedenberg F, Miller LS, et al. Endoscopic pyloric injection of botulinum toxin A for the treatment of refractory gastroparesis. Gastrointest Endosc 2005; 61:833.
- Friedenberg FK, Palit A, Parkman HP, et al. Botulinum toxin A for the treatment of delayed gastric emptying. Am J Gastroenterol 2008; 103:416.
- Arts J, Holvoet L, Caenepeel P, et al. Clinical trial: a randomized-controlled crossover study of intrapyloric injection of botulinum toxin in gastroparesis. Aliment Pharmacol Ther 2007; 26:1251.
- INITIAL MANAGEMENT
- Dietary modification
- Hydration and nutrition
- Optimize glycemic control
- - Metoclopramide
- - Domperidone
- - Macrolide antibiotics
- - Cisapride
- REFRACTORY SYMPTOMS
- Decompression and feeding
- Tricyclic antidepressants
- Other therapies
- Gastric electrical stimulation
- MANAGEMENT OF ACUTE EXACERBATIONS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS