01Approach to the Critical Patient/attcp54

Immediate priorities

›Airway and aspiration risk

›Active vomiting with decreased mental status

›Aspiration risk high

›Positioning: lateral decubitus or upright

›Inability to protect airway

›Intubation preparation

›Suction at bedside

›Recurrent emesis with hematemesis

›Mallory-Weiss tear concern

›Upper GI bleeding workup

›Hemodynamic assessment

›Dehydration and shock physiology

›SBP < 90 mmHg

›HR > 110 as dehydration marker

›Orthostatic vital signs

›IV access and fluid resuscitation

›Two large-bore IV lines

›Normal saline or lactated Ringer bolus 500 mL to 1 L

›Electrolyte emergency

›Hypokalemia < 2.5 mmol/l with arrhythmia risk

›Metabolic alkalosis from protracted vomiting

›Glucose emergency in diabetic patients

›DKA trigger by gastroparesis

›pH < 7.3 or bicarbonate < 18 mmol/l

›Anion gap > 12 mmol/l

›Ketones positive

›Severe hyperglycemia independently delays gastric emptying

02History/hx95

Presenting symptoms

›Core symptom complex

›Nausea

›Most troubling symptom in > 40% of patients

›Near-universal in gastroparesis

›Correlates with severity of gastric emptying delay

›Vomiting

›Often partially digested food > 1 hour after meals

›Quantify frequency and volume

›Relief of nausea after vomiting is characteristic

›Early satiety and postprandial fullness

›Inability to finish a normal-sized meal

›Symptom onset within 30 minutes of eating

›Abdominal pain

›Increasingly recognized especially in idiopathic gastroparesis

›Often epigastric and postprandial

›May be the dominant presenting symptom

Symptom timeline and triggers

›Temporal pattern

›Symptom onset

›Acute exacerbation vs chronic baseline

›Prior episodes and hospitalizations

›Relationship to meals

›Worsening postprandially

›Triggers: large meals, high-fat foods, high-fiber foods

›Carbonated beverages worsen bloating

›Severity classification context

›Mild: symptoms managed with dietary modification

›Moderate: regular antiemetic or prokinetic use required

›Severe: unable to maintain oral nutrition, frequent ED visits

›Weight and nutrition

›Weight loss

›Greater than 5 to 10% body weight is alarming

›Reduced caloric intake primary mechanism

›Paradoxical weight gain in type 2 diabetes patients

›Dietary restriction history

›Foods eliminated due to symptoms

›Liquid-dominant diet adoption

Alarm features

›Red flag symptoms requiring urgent evaluation

›Hematemesis or coffee-ground emesis

›Mallory-Weiss tear from forceful vomiting

›Alternative upper GI pathology

›Dysphagia

›Mechanical obstruction concern

›Esophageal pathology co-existing

›Fever with abdominal pain

›Perforation

›Cholecystitis

›Pancreatitis

›New-onset symptoms in older adults

›Malignancy concern

›Gastric outlet obstruction from tumor

Risk factors and etiology history

›Diabetic etiology

›Type 1 or type 2 diabetes

›Duration of disease

›HbA1c and glycemic control

›Diabetic neuropathy complications present

›Poor glycemic control worsens gastroparesis

›Hyperglycemia independently delays gastric emptying

›Surgical history

›Prior gastric or abdominal surgery

›Fundoplication

›Bariatric surgery

›Vagotomy or esophagectomy

›Vagal nerve injury risk with upper GI surgery

›Medication review

›Opioids: major contributor to delayed emptying

›Cessation recommended when possible

›GLP-1 receptor agonists

›Semaglutide, liraglutide, tirzepatide

›Increasingly recognized cause

›Other offending agents

›Anticholinergics

›Calcium channel blockers

›Dopamine agonists

›Clonidine and lithium

›Post-viral history

›Preceding viral illness

›CMV, EBV, norovirus

›Often post-infectious idiopathic onset

›Connective tissue and neurologic

›Scleroderma: skin tightening, Raynaud phenomenon

›Parkinson disease: autonomic dysfunction

›Amyloidosis

Social and psychiatric history

›Cannabis use

›Cannabinoid hyperemesis syndrome key mimic

›Compulsive hot bathing behavior

›Episodic pattern

›Heavy use may worsen gastroparesis symptoms

›Depression and anxiety

›Independently associated with worse symptom severity

›Higher healthcare utilization association

›Psychiatric comorbidity common

›Healthcare utilization pattern

›Younger age, Black race, lower income independently associated with frequent ED visits

›39% of patients had prior ED visits in one cohort

›23% had prior hospitalizations

03Physical Exam/exam59

Vital signs

›Hemodynamic and dehydration assessment

›Heart rate

›Tachycardia as dehydration marker

›HR > 100 at rest requires IV fluid consideration

›Blood pressure

›Orthostatic drop: SBP fall > 20 mmHg on standing

›SBP < 90 mmHg as shock marker

›Temperature

›Fever suggests alternative or complicating diagnosis

›Afebrile expected in uncomplicated gastroparesis

›Respiratory rate

›Tachypnea with aspiration or metabolic acidosis

Abdominal exam

›Key findings

›Succussion splash

›Fluid sloshing audible > 3 hours after eating

›Suggests significant gastric retention

›Also seen in gastric outlet obstruction

›Distension

›Epigastric bloating

›Diffuse distension raises SBO concern

›Tenderness

›Usually mild and diffuse in gastroparesis

›Focal or peritoneal signs indicate alternative pathology

›Bowel sounds

›Absent or hypoactive

›Hyperactive with high-pitched tinkling raises SBO concern

04Differential Diagnosis/ddx55

Life-threatening mimics

›Surgical emergencies

›Gastric outlet obstruction

›ICD-10 K31.1

›Peptic ulcer disease, malignancy

›Bilious vomiting suggests distal obstruction

›Small bowel obstruction

›ICD-10 K56.60

›Bilious vomiting, diffuse distension, high-pitched bowel sounds

›Air-fluid levels on plain film

›Mesenteric ischemia

›ICD-10 K55.0

›Severe pain out of proportion to exam

›Lactate elevated

›Perforation

›ICD-10 K63.1

›Pneumoperitoneum on upright CXR or CT

Functional and motility disorders

›Gastroparesis mimics and overlapping conditions

›Functional dyspepsia

›ICD-10 K30

›Normal gastric emptying in 70 to 80% of cases

›Significant symptom overlap; may exist on same spectrum

›Cyclic vomiting syndrome

›ICD-10 G43.A0

›Episodic with symptom-free intervals

›Younger patients, migraine association

›Cannabinoid hyperemesis syndrome

05Laboratory Tests/lt46

Core metabolic labs

›Electrolytes and renal function

›Basic metabolic panel

›Hypokalemia from vomiting: K < 3.5 mmol/l

›Hypochloremic metabolic alkalosis: Cl < 95 mmol/l, bicarbonate > 28 mmol/l

›Renal function for antiemetic dosing

›Magnesium and phosphorus

›Refeeding risk assessment

›Malnutrition depletion pattern

›Glucose

›Hyperglycemia independently delays gastric emptying

›Target glucose < 11 mmol/l during acute exacerbation

Endocrine and organ function

›Diabetic evaluation

›HbA1c

›Glycemic control over prior 3 months

›HbA1c > 8.5% associated with worse gastroparesis severity

›Blood glucose

›Glucose > 15 mmol/l impairs antral contractility

›DKA screen if glucose > 14 mmol/l with symptoms

›Thyroid function

›TSH

›Exclude hypothyroidism as reversible cause

›Normal range 0.4 to 4.0 mIU/l

›Hepatic and pancreatic

›Liver function panel

›Hepatobiliary disease exclusion

›Bilirubin for jaundice workup

06Diagnostic Tests/dt90

Scoring Systems

›Gastroparesis Cardinal Symptom Index (GCSI)

›Validated patient-reported outcome measure

›Three subscales: nausea/vomiting, postprandial fullness, bloating

›Score 0 to 5 per item; total 0 to 45

›Score > 2.5 indicates moderate-to-severe disease

›Clinical utility

›Tracks treatment response

›Correlates with gastric emptying delay in some studies

›Does not replace objective gastric emptying testing

›GCSI-Daily Diary (GCSI-DD)

›Daily version for clinical trials

›Captures symptom variability

›Endorsed by FDA for gastroparesis trials

›Patient Assessment of Upper GI Symptoms (PAGI-SYM)

›Broader upper GI symptom assessment

›20-item tool

›Includes heartburn and regurgitation domains

›Clinical Global Patient Assessment

›Overall impression scale

›Used as secondary endpoint in drug trials

›Not a diagnostic tool

MRI

›MRI gastric motility

›Emerging research tool

›Magnetic resonance gastric emptying

›No radiation advantage over scintigraphy

›Limited clinical availability

›MRI abdomen indications

›Suspected malignancy characterization

›Connective tissue disease organ involvement

›Complex surgical anatomy assessment

›Limitations in acute gastroparesis

›Not available for acute ED diagnosis

›Motion artifact from active nausea

›Not superior to standard gastric emptying scintigraphy

CT

›CT abdomen and pelvis

›Indications in gastroparesis

›Exclude mechanical obstruction when suspected

›SBO exclusion with high clinical suspicion

›Malignancy evaluation in new-onset symptoms

›CT findings in gastroparesis

›Gastric distension with retained food and fluid

›No transition point distinguishes from SBO

›Extrinsic compression assessment

›CT for complications

›Bezoar detection: retained concretion of food material

›Perforation: free air subdiaphragmatic

›Pancreatitis or cholecystitis as alternative diagnosis

›Contrast considerations

›IV contrast for vascular and solid organ assessment

›Oral contrast may precipitate vomiting; use judiciously

›CT angiography

›Superior mesenteric artery syndrome

›Aortomesenteric angle < 25 degrees

›Aortomesenteric distance < 8 mm

›Median arcuate ligament syndrome

›Celiac artery compression on expiratory images

Ultrasound

›Abdominal ultrasound

›Biliary tract evaluation

›Gallstones as alternative or complicating diagnosis

›Common bile duct dilation

›First-line for right upper quadrant pain

›Gastric antrum assessment

›Antral cross-sectional area correlates with gastric content volume

›Research application: not standard of care

›Pyloric assessment

›Pyloric stenosis in pediatric patients

›Pyloric wall thickness > 3 mm in adults raises concern

›Gastric emptying scintigraphy (gold standard)

›Standard nuclear medicine study

›Tc-99m labelled solid meal (4-hour protocol)

›Images at 0, 1, 2, and 4 hours

›Delayed emptying defined as > 10% retention at 4 hours

›> 60% retention at 2 hours also diagnostic

›Protocol requirements

›Withhold prokinetics 48 to 72 hours prior

›Glucose should be < 15 mmol/l for valid result

›Not performed during acute hospitalization typically

›Alternative motility tests

›Wireless motility capsule: whole gut transit assessment

›13C-octanoic acid breath test: radiation-free alternative

›Antroduodenal manometry: motility pattern in complex cases

›Upper endoscopy

›Required prior to gastroparesis diagnosis

›Excludes mechanical obstruction

›Peptic ulcer disease

›Malignancy

›Pyloric stenosis

›Retained food in stomach after overnight fast

›Suggestive but not diagnostic of gastroparesis

›Can be seen with delayed emptying from any cause

07Disposition/dispo52

Admission indications

›Hospital admission criteria

›Intractable vomiting

›No response to IV antiemetics in ED

›Unable to tolerate oral medications

›Dehydration and electrolyte derangements

›Requires IV correction

›Potassium < 3.0 mmol/l

›Metabolic alkalosis with pH > 7.50

›Inability to maintain oral intake

›NPO for > 24 to 48 hours

›Caloric deficit requiring nutritional support

›Diabetic complications

›DKA triggered by gastroparesis

›Severe hyperglycemia requiring insulin drip

›Alternative surgical diagnosis not excluded

›Peritoneal signs

›Imaging findings requiring monitoring

›Mean hospital length of stay for gastroparesis: 5.8 days

›Mean ED-to-admission rate: approximately 25%

ICU considerations

›ICU level care

›Aspiration with respiratory compromise

›SpO2 < 92% requiring supplemental oxygen

›Intubation requirement

›Hemodynamic instability

›Septic shock from aspiration pneumonia

›Vasopressor requirement

08Treatment/t116

Fluid and electrolyte resuscitation

›IV fluid management

›Dehydration resuscitation

›Normal saline 0.9% or lactated Ringer

›500 mL to 1 L bolus then reassess

›Target urine output > 0.5 mL/kg/hour

›Potassium replacement

›KCl 10 to 20 mmol/hour IV for K < 3.5 mmol/l

›Cardiac monitoring during rapid replacement

›Oral supplementation when tolerating PO

›Glucose management in diabetic patients

›Insulin drip for glucose > 14 mmol/l with DKA

›Subcutaneous insulin correction for hyperglycemia without DKA

›Target glucose 6 to 11 mmol/l during acute episode

Antiemetics

›First-line antiemetics in the ED

›Ondansetron IV

›4 to 8 mg IV every 6 hours PRN

›Most commonly used in gastroparesis ED visits (61%)

›Does not improve gastric emptying

›Well-tolerated, minimal sedation

›Prochlorperazine IV

›5 to 10 mg IV every 4 to 6 hours PRN

›Antiemetic via D2 antagonism

›Extrapyramidal side effects: diphenhydramine 25 to 50 mg IV if needed

›Promethazine

›12.5 to 25 mg IV or IM every 4 to 6 hours PRN

›Sedating: caution in older adults

›Available as rectal suppository

›Haloperidol IV

›5 mg IV single dose

›Small RCT showed significant pain and nausea reduction in acute gastroparesis

›ACG does not recommend routine use

›QTc prolongation risk: baseline ECG before use

Prokinetics

›Metoclopramide

›First-line prokinetic; only FDA-approved agent for gastroparesis

›5 to 10 mg IV or PO three times daily

›Administer 15 minutes before meals

›Mechanism: D2 antagonist and 5-HT4 agonist

›Safety considerations

›Black box warning: tardive dyskinesia risk

›Limit use to 12 weeks maximum

›TD risk approximately 0.1% per 1000 patient-years with short-term use

›Contraindicated in Parkinson disease

›Nasal spray formulation available for nausea

›15 mg intranasally before meals

›Avoids first-pass effect; useful when vomiting limits oral route

›Erythromycin

›Motilin receptor agonist; best acute prokinetic

›IV: 3 mg/kg IV every 8 hours for acute inpatient use

›PO: 50 to 250 mg three to four times daily before meals

›Rapid tachyphylaxis: use limited to 4 weeks

›Adverse effects

›QTc prolongation: baseline ECG

›Drug interactions via CYP3A4

›Nausea and diarrhea at higher doses

›Domperidone

›Peripheral D2 antagonist; limited CNS penetration

›10 mg three times daily before meals

›FDA IND required in the United States

›QTc prolongation risk: baseline ECG and monitoring

›Preferred in Parkinson disease over metoclopramide

Dietary modification

›First-line non-pharmacologic treatment

›Small particle diet

›Soft foods chewed into small pieces

›RCT evidence for symptom reduction and improved gastric emptying in diabetic gastroparesis

›ACG guideline recommendation

›Meal frequency and size

›Four to six small meals per day rather than three large

›Caloric density maintained through frequency

›Food composition targets

›Low fat: fat delays gastric emptying

›Low residue: insoluble fiber forms bezoars

›Avoid fatty, spicy, acidic, and carbonated foods

›Liquid caloric supplementation

›Liquids empty more rapidly than solids

›Nutritional supplement drinks: Ensure, Boost

›Soups and smoothies for caloric intake

Refractory and advanced therapies

›Procedural interventions

›Gastric peroral endoscopic myotomy (G-POEM)

›Endoscopic pyloromyotomy

›Reduces pyloric tone

›Emerging evidence for refractory gastroparesis

›Gastric electrical stimulation (GES)

›Enterra device: FDA Humanitarian Use Device

›Reduces nausea and vomiting; does not reliably improve gastric emptying

›Requires surgical implantation

›Pyloric botulinum toxin injection

›Endoscopic injection into pylorus

›RCT evidence not supportive of benefit vs placebo

›Not routinely recommended by ACG or AGA

›Nutritional support escalation

›Jejunal enteral nutrition

›Nasojejunal tube for acute nutritional support

›Jejunostomy for long-term enteral access

›Bypasses gastric dysmotility

›Preferred over parenteral nutrition when GI tract functional distally

›Parenteral nutrition

›Reserved for failure of enteral route

›Short-term during acute exacerbations

›Central venous access required

›Infectious complication risk higher than enteral route

›Venting gastrostomy

›Decompresses stomach in severe cases

›Reduces bloating and pain

›Nutrition delivered via simultaneous jejunal port

›Newer pharmacologic options

›Granisetron transdermal patch

›3.1 mg per 24 hours patch

›Reduced symptoms by 50% in refractory patients

›Changed every 7 days

›Aprepitant

›NK1 receptor antagonist

›Limited data; considered for refractory nausea

›80 mg PO daily

›Avoid nortriptyline

›RCT showed no benefit vs placebo for gastroparesis

›Higher discontinuation rates than placebo

09Special Populations/sp110

Pregnancy

›Gastroparesis in pregnancy

›Physiologic gastric emptying delay in pregnancy

›Progesterone reduces gastric smooth muscle contractility

›Third trimester has greatest delay

›Aspiration risk increased peripartum

›Hyperemesis gravidarum overlap

›> 5% weight loss from vomiting

›Ketonuria from starvation

›Hospital admission often required

›Pre-existing gastroparesis worsens in pregnancy

›Particularly in diabetic gastroparesis patients

›Glycemic control more difficult

›Medication safety in pregnancy

›Ondansetron

›Most commonly used antiemetic in pregnancy

›Category B; avoid in first trimester when possible

›Cleft palate association in early first trimester at high doses

›Metoclopramide

›Category B; used for hyperemesis gravidarum

›Short courses preferred

›Crosses placenta; neonatal extrapyramidal effects risk

›Erythromycin

›Avoid in first trimester if possible

›Hypertrophic pyloric stenosis risk if taken in neonatal period

›Domperidone

›Avoid; limited safety data in pregnancy

›Prochlorperazine

›Used in hyperemesis; category C

›Avoid near delivery: neonatal extrapyramidal effects

›Monitoring and nutrition

›Fetal monitoring when viable gestation during acute illness

›Thiamine supplementation to prevent Wernicke encephalopathy in hyperemesis

›100 mg IV daily before dextrose administration

›Nutritional support via nasojejunal tube if oral intake inadequate

Geriatric

›Older adult considerations

›Age-related physiologic changes

›Reduced gastric acid secretion

›Slowed gastric emptying at baseline

›Reduced thirst sensation increases dehydration risk

›Higher prevalence of polypharmacy

›Multiple agents delay gastric emptying

›Medication reconciliation critical

›Frailty and functional status

›Malnutrition risk higher

›Lower physiologic reserve

›Admission threshold lower

›Medication risks in older adults

›Metoclopramide on Beers Criteria

›Avoid in older adults when possible

›Extrapyramidal side effects and tardive dyskinesia risk higher

›QTc prolongation risk increased

›If used, lowest effective dose for shortest duration

›Prochlorperazine

›Beers Criteria: avoid in older adults

›Anticholinergic effects

›Fall risk from sedation and orthostasis

›Promethazine

›Beers Criteria: avoid in older adults

›Excessive sedation and delirium risk

›Preferred alternatives in older adults

›Ondansetron: fewer CNS effects

›Mirtazapine: stimulates appetite, antiemetic properties

›Domperidone: limited CNS penetration

›Geriatric-specific complications

›Delirium from dehydration or metabolic disturbance

›MMSE or CAM assessment

›Aspiration risk higher

›Swallow function impairment common

›Head of bed elevation critical

›Renal dosing adjustments

›Creatinine clearance calculation essential

›CrCl < 30 mL/min requires dose modification

Pediatrics

›Pediatric gastroparesis

›Epidemiology differences

›Less common than in adults

›Post-viral etiology prominent in children

›Idiopathic most common after viral onset

›Differential diagnosis priority differences

›Pyloric stenosis in infants (< 6 weeks)

›Foreign body ingestion

›Cyclic vomiting syndrome more common in children

›Abdominal migraine in school-age children

›Pediatric diagnostic considerations

›Gastric emptying scintigraphy in children

›Age-specific norms required for interpretation

›Liquid and solid protocols differ from adults

›Radiation dose minimization protocols

›Upper endoscopy under general anesthesia in young children

›Pediatric pharmacologic management

›Ondansetron

›0.1 to 0.15 mg/kg IV or PO every 8 hours

›Maximum 4 mg per dose

›Weight-based dosing

›Metoclopramide in children

›0.1 mg/kg IV or PO before meals

›Maximum 0.5 mg/kg per day

›Dystonic reactions more common in children than adults

›Diphenhydramine available for acute dystonia: 1 mg/kg IV

›Erythromycin

›3 to 6 mg/kg IV every 6 hours for acute management

›Oral: 3 to 5 mg/kg three to four times daily

›Cyproheptadine

›Antihistamine and serotonin antagonist

›0.25 to 0.5 mg/kg per day divided three times daily

›Used in cyclic vomiting syndrome in children

›May stimulate appetite

›Nutritional support in pediatrics

›Nasogastric tube for acute nutrition

›Jejunal feeding if nasogastric route fails

›Growth and development monitoring critical

10Background/b83

Epidemiology

›Prevalence and burden

›Prevalence in general population

›Approximately 37.8 per 100,000 women

›Approximately 9.6 per 100,000 men

›Female sex prevalence approximately four times higher than male

›Etiology distribution in tertiary care

›Idiopathic gastroparesis: largest group

›Diabetic gastroparesis: second most common

›Postsurgical: third most common

›Healthcare utilization

›Gastroparesis ED visit rates increasing

›Mean admission rate from ED approximately 25%

›Mean inpatient length of stay 5.8 days

›Annual direct healthcare costs in the hundreds of millions in the US

›Risk populations

›Diabetes mellitus type 1 and type 2

›Up to 30 to 50% of type 1 diabetics have evidence of delayed gastric emptying

›Type 2 diabetics at lower but significant risk

›Demographic risk factors

›Younger age at onset of idiopathic form

›Black race independently associated with frequent ED visits

›Lower socioeconomic status and higher healthcare utilization

›Psychosocial burden

›Depression and anxiety in majority of patients

›Significant quality-of-life impairment

›Work disability common in moderate-to-severe disease

Pathophysiology

›Mechanisms of gastric dysmotility

›Normal gastric emptying physiology

›Fundic accommodation for food storage

›Antral peristaltic waves grind solid food

›Coordinated pyloric opening allows emptying

›Duodenal feedback via GLP-1 and GIP regulates rate

›Neuropathic mechanisms

›Loss of interstitial cells of Cajal (ICC)

›ICC are pacemaker cells of gastric electrical rhythm

›ICC depletion found in surgical specimens of gastroparesis

›Autonomic neuropathy

›Vagal efferent damage impairs fundic relaxation and antral contractions

›Diabetic autonomic neuropathy most common cause

›Enteric nervous system dysfunction

›Loss of nitrergic neurons (nitric oxide)

›Impaired pyloric relaxation

›Myopathic mechanisms

›Scleroderma: fibrosis of smooth muscle

›Amyloidosis: extracellular deposition

›Inflammatory mechanisms

›Post-viral: immune-mediated ICC loss

›Macrophage infiltration and oxidative stress

›Anti-neuronal antibodies in some paraneoplastic cases

›Pyloric dysfunction role

›Pylorospasm contributes to delayed emptying

›Pyloric botulinum toxin target (though RCT evidence does not support benefit)

›G-POEM rationale: pyloromyotomy reduces pyloric tone

›Antroduodenal dyscoordination

›Impaired migrating motor complex

›Bacterial overgrowth risk from reduced interdigestive clearing

Therapeutic Considerations

›Prokinetic pharmacology principles

›Dopamine antagonism at D2 receptors

›Metoclopramide and domperidone mechanism

›Increases antral contraction amplitude

›Reduces pyloric tone

›Motilin receptor agonism

›Erythromycin mechanism

›Mimics phase III migrating motor complex

›Tachyphylaxis via receptor downregulation

›5-HT4 receptor agonism

›Cisapride (withdrawn); metoclopramide partial agonist

›Prucalopride: evidence limited in gastroparesis

›Treatment stratification

›Step 1: dietary modification and offending medication removal

›Step 2: antiemetics and prokinetics

›Step 3: nutritional support escalation

›Step 4: procedural intervention (G-POEM, GES, jejunostomy)

›Evidence base quality

›Gastroparesis trials historically small and heterogeneous

›FDA-approved drugs limited to metoclopramide only

›ACG 2022 guideline: metoclopramide as first-line prokinetic (conditional recommendation, very low evidence)

›AGA 2025 guideline update incorporated G-POEM evidence

›Functional dyspepsia and gastroparesis spectrum recognition changes diagnostic paradigm

›Glycemic control as therapeutic target

›Hyperglycemia > 10 to 15 mmol/l acutely impairs gastric emptying

›Improving HbA1c improves gastroparesis symptoms in diabetic patients

›GLP-1 agonist discontinuation may improve symptoms

11Patient Discharge Instructions/pdi38

copy discharge instructions

›Gastroparesis home care

›Diet: small, frequent meals (4 to 6 per day)

›Soft, low-fat, low-fiber foods

›Soups, smoothies, nutritional supplement drinks are easier to tolerate

›Avoid large meals, fatty foods, fried foods, and carbonated drinks

›Stay upright for at least 1 hour after eating

›Do not lie down immediately after meals

›Elevate head of bed 30 degrees for sleep

›Stay hydrated

›Small sips of clear fluids frequently if feeling nauseated

›Oral rehydration solution if unable to tolerate solid food

›Take medications as prescribed

›Antiemetics and prokinetics before meals as directed

›Do not stop without discussing with your doctor

›Avoid opioid pain medications

›Opioids severely worsen gastroparesis

›Acetaminophen preferred for pain

›Diabetic patients: check blood sugar frequently

›Erratic eating patterns alter insulin needs

›Contact your diabetes team for insulin adjustments

›Return to ER immediately if

›Vomiting blood or material that looks like coffee grounds

›Could indicate bleeding in the stomach

›Unable to keep any liquids down for more than 12 to 24 hours

›Severe abdominal pain or your belly becomes hard and rigid

›Signs of dehydration

›Dizziness or lightheadedness when standing

12References/r31

Guidelines and key sources

›Primary guidelines

›ACG Clinical Guideline: Gastroparesis (Camilleri M et al., American Journal of Gastroenterology, 2022)

›Metoclopramide first-line prokinetic: conditional recommendation

›Small particle diet recommended before pharmacotherapy

›Erythromycin for short-term acute inpatient use

›AGA Clinical Practice Guideline on Management of Gastroparesis (Staller K et al., Gastroenterology, 2025)

›Incorporated G-POEM and pyloric interventions

›Dietary modification first-line

›AGA Clinical Practice Update: Management of Medically Refractory Gastroparesis (Lacy BE et al., Clinical Gastroenterology and Hepatology, 2022)

›Step-up approach to refractory disease

›Nutritional support escalation strategy

›Supporting references

›Rome Foundation and ISMS Consensus on Idiopathic Gastroparesis (Schol J et al., Lancet Gastroenterology and Hepatology, 2025)

›Idiopathic gastroparesis diagnostic criteria

›Overlap with functional dyspepsia addressed

›Disorders of Gastric Motility (Shin A, Lancet Gastroenterology and Hepatology, 2024)

›Comprehensive review of pathophysiology and treatment

›Pharmacologic Treatments for Gastroparesis (Camilleri M and Jencks KJ, Pharmacological Reviews, 2025)

›Drug mechanisms and clinical evidence review

›Emergency Department presentations for gastroparesis (Shalaby M et al., American Journal of Emergency Medicine, 2025)

›ED utilization data 2016 to 2024

›Dietary Interventions for Gastroparesis systematic review (Eseonu D et al., Advances in Nutrition, 2022)

›Small particle diet RCT evidence

›Gastroparesis in the Hospital Setting (Rangan V and Ukleja A, Nutrition in Clinical Practice, 2021)

›Inpatient management and nutritional support

›2023 American Geriatrics Society Beers Criteria (Steinman MA, Journal of the American Geriatrics Society, 2025)

›Metoclopramide and prochlorperazine avoidance in older adults

Evidence & Review