Jan. 25, 2022
Gastroparesis is characterized by a delay in gastric emptying associated with upper gastrointestinal symptoms and no evidence of a mechanical obstruction. Symptoms include nausea, vomiting, early satiety and postprandial fullness.
Often, idiopathic gastroparesis may develop postoperatively or after an infection. Other conditions and factors associated with gastroparesis include type 1 and type 2 diabetes mellitus, medications that impair gastric emptying (most notably opioids, GLP-1 agonists used for diabetes and tricyclic antidepressants at high doses), neurological disorders, and autoimmune disorders.
Published in 2021, the United European Gastroenterology (UEG) and European Society for Neurogastroenterology and Motility (ESNM) consensus on gastroparesis presents statements on symptom characteristics, pathophysiology, diagnosis and management for this condition.
In a commentary published in Neurogastroenterology & Motility in 2021, Mayo Clinic gastroenterology researchers begin their article by congratulating the ESNM and UEG members for developing comprehensive recommendations on gastroparesis, noting the strength of the systematic literature reviews, and the consensus and grading processes. The commentary's lead author, Michael Camilleri, M.D., is a gastroenterologist at Mayo Clinic in Rochester, Minnesota. Dr. Camilleri's research team focuses on disorders of gastrointestinal motility and function.
Dr. Camilleri and co-authors note that they were in agreement with many of the endorsed statements. However, because the ESNM work group's literature search ended in 2019, the commentary from the Mayo Clinic researchers includes updates of the current state of knowledge related to gastroparesis. Their primary goal was to identify and elaborate on topics where recently published literature provides additional insights that may not have been available while the ESNM document was produced. To achieve this objective, the Mayo Clinic researchers conducted an extensive review of currently available published literature related to each of the ESNM's consensus statement topics.
In this article, Dr. Camilleri and commentary co-author Ting Zheng, M.D., a gastroenterology fellow at Mayo Clinic, elaborate on a few of the updated perspectives discussed in their commentary.
Definitions and symptoms: Pain
Addressing the ESNM's statement about whether abdominal pain is considered a symptom of gastroparesis, Mayo Clinic authors shared findings from the National Institutes of Health gastroparesis consortium published in 2020, in which 90% of patients with either diabetic or idiopathic gastroparesis reported abdominal pain. Consequently, the Mayo Clinic authors suggest that even though pain is not a predominant symptom of gastroparesis, it is a frequent component of the symptoms of patients with this condition.
Epidemiology
Mayo Clinic commentary authors are in agreement that the epidemiological characteristics of gastroparesis are not yet well understood. They note that two objective testing methods to exclude upper gastrointestinal obstruction and to document delayed gastric emptying (upper gastrointestinal endoscopy and gastric emptying scintigraphy, respectively) are not widely used to confirm the diagnosis upon which the epidemiology is based. Hence, the authors assert that it is essential for future studies to incorporate those objective measures to gain better insights about the epidemiology of gastroparesis.
Pathophysiology
The Mayo Clinic commentary authors observe that although multiple factors are likely to be responsible for the etiology of gastroparesis symptoms, delayed gastric emptying plays an essential role and should be considered mandatory for the diagnosis of gastroparesis. They note that multiple studies summarized in Mayo Clinic publications in 2019 and 2020 have demonstrated a positive association between optimally measured gastric emptying and symptoms, as well as documenting improvement in upper gastrointestinal symptoms with acceleration of gastric emptying.
Treatment
Treatment of gastroparesis continues to require a multidisciplinary approach that includes dietary adjustments, nutritional support, prokinetic agents and pyloric interventions. Dr. Camilleri comments that some of the recently introduced therapeutic strategies are very encouraging. "Within the U.S., no new drugs have been approved by the Food and Drug Administration for several decades. But I do believe we are on course to having more to offer our patients. So, I am optimistic that we are on the right track."
Dietary adjustments
Mayo Clinic commentary authors agree with ESNM statements related to dietary adjustments. "Small portion, frequent meals consisting of food with high-carbohydrate, low-fat, low-fiber content is the first step in the management of gastroparesis," explains Dr. Zheng. "Homogenized food and liquid nutrition tend to be well tolerated. In patients with refractory nausea and vomiting, oral or percutaneous jejunal nutrition may be necessary. Parenteral nutrition is associated with high risk of complications and should be reserved for patients with more-severe disease and intolerance of enteral feeding."
Proton pump inhibitors
In their commentary, Mayo Clinic authors observe that gastroesophageal reflux disease commonly coexists with gastroparesis, for which proton pump inhibitors may be helpful.
Prokinetics
Dr. Zheng adds that "prokinetics and anti-emetics are the first line pharmacological treatments in patients with gastroparesis. While the correlation between symptomatic improvement and the enhancement of gastric emptying rate remains controversial, recent evidence based on studies with optimal measurement of gastric emptying (based on emptying of solids over at least three hours) demonstrates clinical efficacy of prokinetics that are associated with accelerated gastric emptying."
NK1 antagonists
Recent study data suggest the efficacy of NK1 antagonists, such as aprepitant and the experimental medication tradipitant, for at least some of the cardinal symptoms of gastroparesis such as nausea and vomiting.
Gastric peroral endoscopic pyloromyotomy (G-POEM)
Interventions directed at the pylorus have gained popularity in recent years based on many open-label trials. Sham-controlled trials are required.
Conclusions
In closing their commentary, Dr. Camilleri and co-authors commend the ESNM work group's extensive literature review and identify five high-priority areas that require the attention of researchers in gastroparesis to advance the field.
- Consensus endorsement of delayed gastric emptying, measured at least three hours after ingestion of a solid meal, to facilitate consistent diagnosis
- Performance of epidemiological studies using optimal gastric emptying measurement (more feasible using Food and Drug Administration-approved stable isotope breath test, which was originally validated at Mayo Clinic) as the basis for diagnosis
- Further research including gastric biopsies to address intrinsic etiopathologic mechanisms
- Discovery of effective and safe prokinetics as well as optimized placebo-controlled trials to define the role of prokinetics and other treatments
- Investigation of standardized predictors of success with pyloric interventions, whether performed by endoscopy or laparoscopy
For more information
Schol J, et al. United European Gastroenterology (UEG) and European Society for Neurogastroenterology and Motility (ESNM) consensus on gastroparesis.12060 United European Gastroenterology Journal. 2021;9:287.
Camilleri M, et al. A North American perspective on the ESNM consensus statement on gastroparesis. Neurogastroenterology & Motility. 2021;33:e14174.
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