Guide Express ACG New Gastroparesis Guide Essentials Quick Look

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Gastroparesis is characterized by symptoms suggestive of food retention in the stomach, objective evidence of delayed gastric emptying, and no mechanical obstruction
of the gastric outflow tract.
This
is increasingly encountered in clinical practice.
These guidelines summarize perspectives on risk factors, diagnosis, and management (including diet, pharmacology, device, and pylorus-specific interventions) for adults and represent the official practice recommendations
of the American College of Gastroenterology.
In August 2022, the American College of Gastroenterology (ACG) issued guidelines to document, summarize, and update the evidence, updating the 2013 ACG guidelines to summarize the risk factors, diagnosis, and treatment of gastroparesis in adults, and to develop recommendations
for the clinical management of gastroparesis.
The recommendations of the guide are compiled below and shared
with readers.

Table 1 Recommendations for gastroparesis

1.
In patients with diabetic gastroparesis, optimal glycaemic control is recommended to reduce the risk of future exacerbations of gastroparesis (conditionally recommended, low-certainty evidence).

2.
SGE is the standard test
for evaluating gastroparesis in patients with upper gastrointestinal symptoms.
Recommended testing methods include assessing the emptying of solid meals over 3 hours or more (highly recommended, moderate-certainty evidence).

3.
The use of radiopaque marker (ROM) testing in the diagnostic evaluation of gastroparesis in patients with upper GI symptoms is not recommended (conditionally recommended, very low-certainty evidence).

4.
The wireless powered capsule test may be an alternative to SGE evaluation for gastroparesis in patients with upper GI symptoms (conditionally recommended, low-quality evidence).

5.
The stable isotope (13C-spirulina) breath test is a reliable test (conditionally recommended, low-quality evidence)
for the evaluation of gastroparesis in patients with upper GI symptoms.

6.
Dietary management of gastroparesis should include a small-grain diet to increase the likelihood of symptom relief and enhance gastric emptying (conditionally recommended, low-quality evidence).

7.
For people with idiopathic and diabetic gastroparesis, pharmacotherapy should be considered to improve gastroparesis and gastroparesis symptoms, taking into account the benefits and risks of treatment (conditionally recommended, low-quality evidence).

8.
For people with gastroparesis, we recommend metoclopramide rather than refractory symptoms (conditionally recommended, low-quality evidence).

9.
For patients with gastroparesis approved for domperidone, we recommend domperidone for symptom management (conditionally recommended, low-quality evidence).

10.
For people with gastroparesis, we suggest using 5-HT4 agonists rather than no treatment to improve gastric emptying (conditionally recommended, low-quality evidence).

11.
Patients with gastroparesis are recommended to use antiemetics to improve symptom control; However, these drugs do not improve gastric emptying (conditionally recommended, low-quality evidence).

12.
CNS modulators are not recommended for the management of gastroparesis (highly recommended, moderate-certainty evidence).

13.
Current data do not support the use of ghrelin agonists for the management of gastroparesis (highly recommended, moderate-certainty evidence).

14.
Current data do not support the use of haloperidol for gastroparesis (conditionally recommended, low-quality evidence).

15.
Electrical gastric stimulation (GES) may be considered as a device for humanitarian use (HUD) to control symptoms of gastroparesis (conditionally recommended, low-quality evidence).

16.
Acupuncture alone or in combination with prokinetics may be beneficial in symptom control
in patients with gastroparesis.
Acupuncture cannot be recommended to be beneficial for other causes of gastroparesis (conditionally recommended, very low-certainty evidence).

17.
Herbal remedies such as rikkunshito or STW5 (Iberogast) are not recommended for the treatment of gastroparesis (conditionally recommended, low-quality evidence).

18.
In patients with gastroparesis, EndoFLIP assessment may play a role in characterizing pyloric function and predicting treatment outcomes following orificopyloric myostomy (conditionally recommended, very low-certainty evidence).

19.
Based on randomised controlled trials (strongly recommended, moderate-quality evidence), intra-pyloric injection of botulinum toxin
is not recommended in people with gastroparesis.

20.
For patients with gastroparesis who do not respond to medical therapy, we suggest that pyloric myostomy is preferable to no treatment for symptom control (conditionally recommended, low-quality evidence).

Conclusion and outlook

This guideline focuses on the diagnosis and treatment of gastroparesis in adults, including diet, pharmacology, instrumentation, and interventions for pylorus.

Recommendations are guided
by assessments using the GRADE methodology.
However, this is an area where a lot of innovation, validation, and research is underway that could influence future iterations
of these guidelines.
In particular, the following have potential future implications for the management of gastroparesis: The diagnostic value of wireless powered capsules for gastroparesis and for measuring pangastrointestinal transport and pressure curves and autonomic nervous system dysfunction are being studied
.
Similarly, research is exploring the best ways to select and individualize patients for treatment, including recording circulating antibodies, pylorometry and high-resolution anterior gastroduodenal manometry, extensive surface EGG (high-resolution electrogram), and full-thickness antrum and pyloric biopsy
.
These advances should clarify the role of
immunotherapy, novel drugs, pyloric interventions, bioelectrotherapy, and surgical approaches to gastroparesis.