2023 update on the clinical management of gastroparesis

ABSTRACTIntroduction Gastroparesis is characterized by symptoms suggesting gastric retention of food and objective evidence of delayed gastric emptying in the absence of a mechanical obstruction. Nausea, vomiting, early satiety, and postprandial fullness are the classic symptoms of gastroparesis. Gastroparesis is increasingly encountered by physicians. There are several recognized etiologies of gastroparesis, including diabetic, post-surgical, medication-induced, post-viral, and idiopathic.Areas covered A comprehensive literature review was conducted to identify studies discussing gastroparesis management. Dietary modifications, medication adjustments, glucose control, antiemetic agents, and prokinetic agents are all part of gastroparesis management. In this manuscript, we detail treatments evolving for gastroparesis, including nutritional, pharmaceutical, device, and recent advanced endoscopic and surgical therapies. This manuscript concludes with a speculative viewpoint on how the field will evolve in 5 years' time.Expert opinion Identification of the dominant symptoms (fullness, nausea, abdominal pain, and heartburn) helps to direct management efforts of the patients. Treatments for refractory (treatment resistant) symptoms may include gastric electric stimulation and intra-pyloric interventions like botulinum toxin and endoscopic pyloromyotomy. Understanding the pathophysiology of gastroparesis, relating pathophysiologic abnormalities to specific symptoms, new efficacious pharmacotherapies, and better understanding of the clinical predictors of response of therapies, are priorities for future research in the field of gastroparesis.KEYWORDS: Gastroparesismetoclopramidegastric accommodationgastric emptyingprokineticsbotulinumpyloromyotomy Article highlights The main symptoms of gastroparesis include nausea, vomiting, early satiety, and postprandial fullness.Gastric emptying scintigraphy is the standard for diagnosis and can provide further information on the pathophysiology and symptoms of gastroparesis.Current treatment options include dietary, prokinetic, antiemetic, and symptom modulatory treatments.Metoclopramide remains the only FDA approved drug for gastroparesis; new agents are being studied for hopeful approval.Drugs under development primarily target enhanced gastric emptying, including dopaminergic D2/3 receptor antagonists and 5HT-4 receptor agonists.Symptom modulators for gastroparesis are often used to treat nausea and vomiting in gastroparesis; others may address the abdominal pain that patients may have. Currently, 5HT3 receptor antagonists and neurokinin-1 receptor antagonists are being evaluated for nausea and vomiting.The pylorus is one of the novel targets of treatment with the potential to enhance stomach motor functioning.Endoscopic pyloromyotomy, or G-POEM, has good evidence supporting its clinical efficacy and safety in the treatment of some patients with gastroparesis. EndoFLIP of the pyloric sphincter and botulinum toxin injection of the pylorus are used to predict who might respond to more invasive treatments, such as pyloromyotomy or pyloroplasty.Tailoring patient treatment to symptoms should be the main drive for refractory gastroparesis.Advances in the diagnosis and treatment of gastroparesis are promising due to a better understanding of the natural history, pathophysiology, and the symptoms impacting on patients' quality of life.Declaration of interestsThe authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.Reviewer disclosuresPeer reviewers in this manuscript have no relevant financial or other relationships to disclose.Additional informationFundingThis paper was not funded.