ACG updates gastroparesis guidelines for diagnosis, treatment amid ‘ongoing innovation’
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The American College of Gastroenterology has issued a new guideline for the diagnosis and management of gastroparesis, which recently was published in The American Journal of Gastroenterology.
“The objective of this new guideline is to document, summarize and update the evidence and develop recommendations for the clinical management of gastroparesis (GP),” Michael Camilleri, MD, DSc, MRCP, MACG, AGAF, professor of gastroenterology and hepatology at Mayo Clinic in Rochester, Minnesota, and colleagues wrote. “It is necessary to acknowledge the limitations of guideline recommendations on therapies in the absence of FDA-approved therapies for GP in the United States and the limitation in duration of prescription to 3 months for the only currently approved medication, metoclopramide.”
The updated recommendations build upon previous guidelines published in 2013, which focused on assessment and correction of nutritional state, symptom relief, improvement of gastric emptying and, in patients with diabetes, glycemic control.
From February 2019 to July 2021, Camilleri and colleagues conducted extensive literature searches and screened 1,908 references, identifying 121 for inclusion and evidence review. They then developed 20 recommendations for the diagnosis and management of GP using the Grading of Recommendations, Assessment, Development and Evaluation process.
Highlights from the updated guideline include:
- Scintigraphic gastric emptying is the standard diagnostic test for GP among patients with upper gastrointestinal symptoms. Suggested method of testing includes evaluation of stomach emptying over 3 hours or more following a solid meal.
- Dietary management of patients with GP should include a small particle diet to increase the likelihood of symptom relief and enhanced gastric emptying.
- Considering both benefits and risks of treatment, pharmacologic therapies should be considered to improve symptoms in patients with idiopathic or diabetic gastroparesis.
- In patients with GP, treatment with metoclopramide is suggested over no treatment for management of refractory symptoms, as is use of 5-HT4 agonists over no treatment to improve gastric emptying. Domperidone, if approved, is suggested for symptom management in patients with GP.
- Pyloromyotomy is suggested over no treatment for symptom control in patients with symptoms refractory to medical therapy. Intrapyloric injection of botulinum toxin is not recommended based on data from randomized controlled trials.
“This guideline has focused on the diagnosis and treatment of GP in adults (including dietary, pharmacological, device and interventions directed at the pylorus),” Camilleri and colleagues concluded. “Nevertheless, this is an area with considerable ongoing innovation, validation and research that is likely to impact future iterations of these guidelines. Such advances should clarify the role of immunotherapies, novel pharmacological agents, pyloric interventions, bioelectric therapy and surgical approaches for GP.”
Perspective
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The new guidelines include the use of the POP procedure for medically refractory patients as well as new information regarding treatment of gastroparesis (GP) with metoclopramide.
When it comes to the available tests to diagnose GP, I would caution that the 4-hour gastric emptying test can vary inside of an individual on a daily or weekly basis. In my practice at Cleveland Clinic, we use the wireless motility capsule when a patient has already had an abnormal gastric emptying test.
The wireless motility capsule can verify the gastric emptying test results and it gives us another way to look at the intestine. The gastric emptying test looks at the stomach only, whereas the wireless motility capsule looks at the entire intestine.
I would like to see more research and data looking at the wireless motility capsule as a diagnostic test for GP. We also need more research to look at the newer technologies that can look at the electrical activity of the intestine – not just its motility. I use an electrogastrogram (EGG) machine, which is like an EKG of the stomach, to look at the electrical system of the stomach and see whether it’s working.
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