goals of treatment in gastroparesis are to reduce symptoms, to maintain a sufficient nutritional state and an optimal weight
with respect to diabetics
NICE suggest (4):
a clinician should consider the diagnosis of gastroparesis in an adult with erratic blood glucose control or unexplained gastric bloating or vomiting, taking into consideration possible alternative diagnoses
consider a trial of metoclopramide, domperidone or erythromycin for an adult with gastroparesis
if gastroparesis is suspected, consider referral to specialist services if:
differential diagnosis is in doubt, or
persistent or severe vomiting occurs
diet and lifestyle
dietary measures are important in the management of gastroparesis
little or no evidence is available that dietary measures work, as they have not been studied in a controlled manner
advice should be targeted at individual intolerances or difficulties with specific food products. Especially, fat rich items and late evening meals should be avoided. Referral to a dietitian may prove helpful
carbonated liquids should be avoided to limit gastric distention. Patients are instructed to take fluids throughout the course of the meal and to sit or walk for 1-2 h after meals.
dietary and lifestyle advice should at least include the following recommendations:
(i) reduce the number of fatty food products,
(ii) eat smaller proportions more frequently during the day,
(iii) remain in an upright position during and after the course of a meal,
(iv) limit the intake of insoluble fibres,
(v) stop smoking, although it should be noted that smoking itself triggers the gastrocolonic reflex and accelerates intestinal transit,
(vi) screen for deficiencies, especially in patients with weight loss and malnutrition and use multivitamin and/or vitamin supplementation, when needed
in cases with severe weight loss or inadequate nutrient intake, enteral feeding through a nasoduodenal tube should be considered
prokinetics
metoclopramide and domperidone
metoclopramide, a dopamine D2 receptor antagonist
both antiemetic and prokinetic properties
antiemetic effect of metoclopramide is based on the blockade of dopamine D2 receptors in the area postrema, located outside the blood-brain barrier, and the vomiting centre
prokinetic effect of metoclopramide is based on the blockade of dopamine D2 receptors in the gastrointestinal tract. Dopamine is known to cause inhibition of motility throughout the gastrointestinal tract. It reduces gastric tone and intragastric pressure and decreases antroduodenal coordination through activation of dopamine D2 receptors
metoclopramide not only shows dopamine D2 receptor antagonist properties but also shows moderate 5-hydroxytryptamine-4 (5HT4) agonist and 5HT3 antagonist properties
domperidone, structurally related to butyrophenones, is also a dopamine D2 receptor antagonist
has similar effects as metoclopramide; however, it does not cross the blood-brain barrier and thus has a slightly less antiemetic effect
both metoclopramide and domperidone may induce hyperprolactinaemia
erythromycin
a macrolide antibiotic that is also a motilin receptor agonist
intravenous form is the most potent stimulant of solid and liquid gastric emptying
motilin is a polypeptide hormone present in the distal stomach and duodenum that increases lower esophageal sphincter pressure and is responsible for initiating the migrating motor complexes (MMC) in the antrum of the stomach
enhances gastric emptying, increases antral contractions and antroduodenal coordination but reduces fundic volume and compliance in health and disease
oral administration of erythromycin is the preferred route for chronic use in patients with gastroparesis. The liquid form of erythromycin may be of additional benefit in gastroparesis, as it does not need to be disintegrated in the stomach
unfortunately, long-term use is limited because of its antibacterial effect and bacterial resistance, and occurrence of desensitization to the therapeutic prokinetic effect
other specialist interventions include:
intrapyloric botulinum toxin injection, gastric pacing or more radical surgical interventions, such as partial or total gastrectomy.
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