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gi.gastroparesis.core.v1

Gastroparesis

gastroenterologychronicadultoutpatientinpatient
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Primary guideline: ACG 2022 Gastroparesis (Camilleri 2022, PMID 35926490 verified via PubMed MCP 2026-05-26). 4-hour solid-phase gastric emptying scintigraphy is the gold-standard diagnostic test (ACG 2022). EGD MANDATORY to exclude mechanical obstruction before GP diagnosis. Tiered management: (1) diet + glycemic + deprescribing → (2) prokinetic (metoclopramide black-box 12-wk limit; domperidone limited-access; erythromycin tachyphylaxis ~4 wks; prucalopride conditional) → (3) antiemetic (ondansetron, aprepitant for refractory) → (4) G-POEM / gastric electrical stimulation / jejunal feeding for refractory. GLP-1 agonists (semaglutide, tirzepatide) are an emerging cause of drug-induced GP; deprescribe where possible (ACG 2022). Botulinum toxin pyloric injection NOT recommended routinely (placebo-controlled trials negative); used as diagnostic predictor for G-POEM in select cases. RxCUIs verified live via RxNav 2026-05-26: metoclopramide=6915, domperidone=3626, erythromycin=4053, prucalopride=2107309, aprepitant=358255.

Entry points (5)

  • symptom
    Chronic nausea, vomiting, early satiety, post-prandial fullness (≥3 months) (ACG 2022)
    nausea_vomiting_post_prandial_fullness
  • symptom
    Unexplained chronic vomiting + diabetes (ACG 2022)
    unexplained_vomiting_chronic_dm
  • lab_abnormality
    4-hour gastric emptying scintigraphy with >10% retention at 4h (ACG 2022 gold standard)
    delayed_gastric_emptying_scintigraphy
  • history
    Post-surgical (fundoplication, gastric/bariatric) or post-viral GP (ACG 2022)
    post_surgical_or_post_viral
  • problem_list
    Existing diabetic gastroparesis on problem list
    diabetic_gastroparesis

Required inputs (14)

  • agerequired
    demographic • used at CONTEXT
    Older age + female prevalence (ACG 2022)
  • weightrequired
    demographic • used at CONTEXT
    Weight loss tracking; severity marker (ACG 2022)
  • diabetes_status_a1crequired
    history • used at CONTEXT
    DM is most common etiology; A1c control reduces GP symptoms (ACG 2022)
  • gastric_surgery_historyrequired
    history • used at CONTEXT
    Post-surgical GP — different prognosis (ACG 2022)
  • medications_opioids_glp1_anticholinergicrequired
    history • used at CONTEXT
    Drug-induced GP — opioids, GLP-1 agonists, anticholinergics, TCAs (ACG 2022)
  • gcsi_score
    symptom • used at RISK_STRATIFICATION
    Gastroparesis Cardinal Symptom Index — severity tracking (ACG 2022)
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Anemia from poor intake
  • tshrequired
    lab • used at INITIAL_WORKUP
    Rule out hypothyroidism as cause (ACG 2022)
  • a1crequired
    lab • used at INITIAL_WORKUP
    DM control; high A1c worsens gastric emptying (ACG 2022)
  • bmprequired
    lab • used at INITIAL_WORKUP
    Electrolyte disturbances from vomiting; renal function for drug dosing
  • lft
    lab • used at INITIAL_WORKUP
    Hepatic function baseline for prokinetic safety
  • gastric_scintigraphy_4hrrequired
    imaging • used at INITIAL_WORKUP
    4-hour solid-phase gastric emptying scintigraphy = ACG 2022 gold standard diagnostic test
  • egd_to_exclude_obstructionrequired
    imaging • used at INITIAL_WORKUP
    EGD mandatory to exclude mechanical obstruction before GP diagnosis (ACG 2022)
  • ekg_qtcrequired
    lab • used at TREATMENT
    Baseline QTc before metoclopramide / domperidone / erythromycin (ACG 2022)

12-phase flow (12)

  1. 1FRAME
    Chronic gastroparesis: delayed gastric emptying without mechanical obstruction; commonly diabetic, idiopathic, post-surgical, or drug-induced (ACG 2022)
    inputs: age, weight
    advance: GP plausible by chronic symptoms + risk factors
  2. 2ENTRY
    Recognize chronic nausea/vomiting/early satiety + DM / post-surgical / unexplained symptoms (ACG 2022)
    advance: one entry trigger present
  3. 3CONTEXT
    Diabetes status + A1c, gastric surgery history, opioid / GLP-1 / anticholinergic use, weight loss, hydration, symptom duration, prior treatments (ACG 2022)
    inputs: diabetes_status_a1c, gastric_surgery_history, medications_opioids_glp1_anticholinergic
    advance: context captured
  4. 4RED_FLAGS
    Severe dehydration, electrolyte disturbances (hypokalemia, hypochloremic alkalosis), severe weight loss (>5-10% baseline) requiring inpatient stabilization (ACG 2022)
    inputs: weight
    advance: red flags identified or excluded
  5. 5INITIAL_WORKUP
    CBC, BMP, TSH, A1c, EGD to exclude mechanical obstruction (MANDATORY before GP diagnosis), 4-hour gastric emptying scintigraphy = ACG 2022 gold standard (ACG 2022)
    inputs: cbc, tsh, a1c, bmp, gastric_scintigraphy_4hr, egd_to_exclude_obstruction
    actions: panel.cbc, panel.renal, panel.thyroid, panel.glucose_a1c
    advance: GP diagnosed with delayed emptying + obstruction excluded
  6. 6BRANCHING_WORKUP
    Wireless motility capsule or 13C-spirulina breath test if scintigraphy unavailable; antroduodenal manometry for rumination / functional vomiting (ACG 2022)
    advance: diagnostic confirmation complete
  7. 7DIFFERENTIAL
    Distinguish from functional dyspepsia, cyclic vomiting syndrome, cannabinoid hyperemesis, rumination syndrome, anorexia nervosa, mechanical obstruction, SMA syndrome (ACG 2022)
    advance: GP confirmed and differentials excluded
  8. 8RISK_STRATIFICATION
    Severity by GCSI / weight loss / hospitalizations / quality of life; etiology subtype (diabetic worse prognosis; idiopathic better; post-surgical variable) (ACG 2022)
    inputs: gcsi_score
    advance: severity + subtype documented
  9. 9TREATMENT
    Tiered approach: dietary modification (small frequent low-fat low-fiber meals) → optimize glycemic control → prokinetic (metoclopramide black-box <12 weeks; domperidone limited-access; erythromycin tachyphylaxis); antiemetic (ondansetron); aprepitant for refractory; gastric peroral endoscopic myotomy (G-POEM) or gastric electrical stimulation for refractory disease (ACG 2022)
    inputs: a1c, ekg_qtc
    advance: tiered treatment plan documented
  10. 10DISPOSITION
    Outpatient: most stable patients; inpatient for severe dehydration / electrolyte disturbance / failure to tolerate PO (ACG 2022)
    advance: destination set
  11. 11MONITORING
    Weight, symptom score (GCSI) q3-6 months; A1c q3 mo if DM; QTc on prokinetic; renal function on metoclopramide; tardive dyskinesia screening at every visit (ACG 2022)
    inputs: weight
    advance: monitoring cadence set
  12. 12FOLLOWUP
    q1-3 mo while titrating; q6 mo stable; nutrition + diabetes coordination; psychiatric / quality-of-life support; discontinue metoclopramide by 12 weeks or when tardive dyskinesia signs (ACG 2022)
    advance: long-term plan documented