AGA releases new clinical guideline for diagnosing and managing gastroparesis

The American Gastroenterological Association (AGA) has released a new clinical guideline with 12 conditional recommendations for diagnosing and managing gastroparesis, a serious and often debilitating disease. Rather than pointing to a single treatment path, the evidence highlights a range of options - underscoring the complexity of gastroparesis and the importance of thoughtful conversations between doctors and patients to tailor an individualized care plan. 

Gastroparesis affects thousands of people, often causing nausea, postprandial fullness, vomiting, discomfort, and major disruptions to quality of life. The condition is complex; treatments may help some patients but not others - making personalized care essential. The guideline is intended as a clinical tool for physicians, not a policy directive.

Every patient's situation is unique. This guideline gives doctors a framework for making decisions with their patients, not for them." 

Osama Altayar, MD, guideline author and AGA guideline panel co-chair 

Guideline author and guideline panel chair Kyle Staller, MD, MPH, noted that public comment played an important role in shaping the guideline. The panel carefully considered how its recommendations might affect both patients and the physicians who care for them, taking care to word recommendations in a way that would not unintentionally restrict patient access to treatments. 

In the guideline, AGA recommends a four-hour study to measure gastric emptying of solid food, rather than shorter studies (two hours or less in duration). For treatment, metoclopramide or erythromycin is considered appropriate for initial pharmacological therapy. Patient preferences, shared decision-making, and supportive evidence should guide other treatment decisions. At the same time, the guideline underscores the urgent need for new therapies and calls for more research and innovation to meet the considerable unmet need in gastroparesis care. 

Dr. Staller emphasized another key challenge: Defining the disease itself. 

"The major gap we face is that gastroparesis is a heterogeneous condition that has not been consistently defined," he said. "A key goal of this guideline was to use diagnostic testing to establish a clearer, more consistent definition anchored by the principle that the symptoms are associated with evidence of slowing of gastric emptying in the absence of obstruction. We've seen progress in related disorders, but much more is needed in gastroparesis so that we can bring hope to this long-suffering group of patients. To get there, we need unified efforts nationwide to improve how studies are designed and treatments are defined - there are still many gaps." 

Key guideline recommendations: 

1. In individuals with suspected gastroparesis, the AGA suggests against the use of a two-hour (or shorter) gastric emptying study compared to a four-hour gastric emptying study to evaluate for delayed gastric emptying. 

2. In individuals with gastroparesis, the AGA suggests using metoclopramide. 

3. In individuals with gastroparesis, the AGA suggests using erythromycin. 

4. In individuals with gastroparesis, the AGA suggests against the use of domperidone as a first-line treatment. 

5. In individuals with gastroparesis, the AGA suggests against the use of prucalopride as a first- line treatment. 

6. In individuals with gastroparesis, the AGA suggests against the use of aprepitant as a first-line treatment. 

7.1 In patients with gastroparesis, AGA suggests against the use of nortriptyline as a first-line treatment. 

7.2 In patients with gastroparesis, AGA suggests against the use of buspirone as a first-line treatment. 

8. In individuals with gastroparesis, the AGA suggests against the use of cannabidiol (CBD) except in the context of a clinical trial. 

9. In patients with gastroparesis refractory to medical management, the AGA suggests against the routine use of botulinum toxin injection (BTI). 

10. In patients with gastroparesis refractory to medical therapy, the AGA suggests against the routine use of gastric peroral endoscopic pyloromyotomy (G-POEM). 

11. In patients with gastroparesis refractory to medical therapy, the AGA makes no recommendation regarding the use of surgical pyloric interventions (pyloromyotomy or pyloroplasty). 

12. In patients with gastroparesis refractory to medical therapy, the AGA suggests against the routine use of gastric electrical stimulation (GES). 

"These are not hard 'yes' or 'no' rules," Dr. Staller said. "If a treatment is 'suggested against,' it doesn't mean never, since it could still be right for some patients. The goal is for patients and providers to weigh benefits, risks, and personal goals." 

Understanding gastroparesis 

Gastroparesis, which reflects the presence of symptoms in the presence of delayed gastric emptying, occurs when the stomach has trouble clearing out its contents. 

Usually, food is broken down to small particle sizes and pushed through the stomach and out to the intestines through the action of muscles in the stomach wall. These muscles are under the control of the stomach's own nerves and special pacemaker-like cells called interstitial cells of Cajal (ICC), as well as by nerves coming from the brain and spinal cord (the vagus and the sympathetic nerves). 

In a person with gastroparesis, the stomach does not function properly, so food moves slowly into the small intestine or stops moving and is retained in the stomach. This may be due to problems in the muscle itself, in the nerves, or in the ICC.