Ten controversies in gastroparesis and a look to the future

Abstract

Background Gastroparesis is a complex, challenging gastrointestinal disorder presenting with upper gastrointestinal symptoms, especially nausea and vomiting, with significant impact on patients' quality of life. After ruling out mechanical obstruction, it is essential to identify delay in gastric emptying for definitive diagnosis. The most common causes are idiopathic (no identified etiology), diabetes mellitus, and postsurgical status. Management of gastroparesis focuses on dietary modifications and treatment directed to symptom relief. Unfortunately, approximately one‐third of patients are refractory to pharmacological therapy, and the effectiveness of the few nonpharmacological options has been questioned. Purpose Extensive review of the literature identifies several uncertainties or controversies regarding the differential diagnosis based on the spectrum of symptoms, the lack of availability of reliable diagnostic test, and questions regarding effective therapeutic options. In this review, we discuss ten controversies regarding gastroparesis: clinical presentation, diagnosis, overlap syndromes, pathophysiology, etiology, as well as pharmacological and nonpharmacological therapeutic options. In addition, we briefly review studies exploring pathological, inflammatory, and molecular disturbances affecting the intrinsic neuromuscular elements that may be involved in the pathophysiology of gastroparesis and may constitute possible therapeutic targets in the future. Finally, we tabulate future research opportunities to resolve these controversies in the management of patients with gastroparesis.

Do prokinetic agents provide symptom relief through acceleration of gastric emptying? An update and revision of the existing evidence

“…Results from both solid meal scintigraphy, the gold standard, 14 and solid meal breath tests for GE were taken into account 15 . As the wireless motility capsule is considered to only indirectly measure GE through the occurrence of gastric phase 3, and as its place in the diagnosis of gastroparesis is not fully established, we did not include papers using the method to assess GE rate 16,17 . Only English research papers were considered.…”

“… 15 As the wireless motility capsule is considered to only indirectly measure GE through the occurrence of gastric phase 3, and as its place in the diagnosis of gastroparesis is not fully established, we did not include papers using the method to assess GE rate. 16 , 17 Only English research papers were considered. Full text papers and abstracts were considered.…”

In silico modelling of the effect of pyloric intervention procedures on gastric flow and emptying in a stomach with gastroparesis

“…A recent guideline published by field experts describes the sequelae for clinical management of the disorder [ 5 ]. Dietary modifications and pharmacological options are the first recommendations, but a large fraction of the patients [ 13 ] do not respond to these treatments. Such patients are labelled refractory and are prescribed surgeries such as the pyloric intervention procedures.…”

Gastric emptying rate and relevance for symptoms

“…This study will be appreciated by many since it highlights the importance of stringent methodology and definitions, a matter where scientific controversies still contribute to specific problems in gastroparesis. 11 Among the basic problems involved that are also mentioned but too often ignored when designing studies is how symptoms are registered when being a primary outcome parameter.…”

“…This study will be appreciated by many since it highlights the importance of stringent methodology and definitions, a matter where scientific controversies still contribute to specific problems in gastroparesis. 11 Among the basic problems involved that are also mentioned but too often ignored when designing studies is how symptoms are registered when being a primary outcome parameter. With modern technology, such as the use of smart phone apps and random symptom registrations, 12 increasing opportunities to have a better quality of symptom data by using devices that also provide a better temporal relationship between symptoms and physiological outcome parameters might be useful.…”