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gi.gastroparesis.core.v1PRODUCTION
gi.gastroparesis.core.v1

Gastroparesis

gastroenterologychronicadult
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Detailed

Chronic gastroparesis: delayed gastric emptying without mechanical obstruction; commonly diabetic, idiopathic, post-surgical, or drug-induced (ACG 2022)

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GP plausible by chronic symptoms + risk factors

Patient inputs (14)

Older age + female prevalence (ACG 2022)

Weight loss tracking; severity marker (ACG 2022)

DM is most common etiology; A1c control reduces GP symptoms (ACG 2022)

Post-surgical GP — different prognosis (ACG 2022)

Drug-induced GP — opioids, GLP-1 agonists, anticholinergics, TCAs (ACG 2022)

Anemia from poor intake

Rule out hypothyroidism as cause (ACG 2022)

DM control; high A1c worsens gastric emptying (ACG 2022)

Electrolyte disturbances from vomiting; renal function for drug dosing

4-hour solid-phase gastric emptying scintigraphy = ACG 2022 gold standard diagnostic test

EGD mandatory to exclude mechanical obstruction before GP diagnosis (ACG 2022)

Baseline QTc before metoclopramide / domperidone / erythromycin (ACG 2022)

Hepatic function baseline for prokinetic safety

Gastroparesis Cardinal Symptom Index — severity tracking (ACG 2022)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationalseveresevere_dehydration_electrolyte
    Severe vomiting with dehydration, hypokalemic hypochloremic metabolic alkalosis, or AKI (ACG 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretardive_dyskinesia_metoclopramide
    New oral / facial / limb dyskinesia on metoclopramide (ACG 2022 FDA black-box)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_malnutrition_weight_loss
    Weight loss >10% baseline, albumin <3.0, BMI <18 (ACG 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereqtc_prolongation_on_prokinetic
    QTc >500 ms on metoclopramide / domperidone / erythromycin (ACG 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterefractory_gp_failed_tier_1_2_3
    Persistent symptoms despite diet, glycemic control, prokinetic, antiemetic for 3-6 months (ACG 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Gastroparesis tiered management — diet + glycemic + prokinetic + antiemetic + endoscopic / surgical (ACG 2022)
axis: gastroparesis_tiered_pathwaystep 1 - Step 1 — Foundational management (all patients)
Selected step "Step 1 — Foundational management (all patients)" — Confirmed gastroparesis (delayed emptying + obstruction excluded)
  • dietary_modification
    first line
    lifestyle
    Small frequent (5-6/day) low-fat low-fiber meals; soft / liquid-blended consistency during flares; chew thoroughly • PO • meals
    triggers: confirmed_GP
    ACG 2022 — dietary modification is first-line for all GP patients
  • optimize_glycemic_control
    first line
    lifestyle
    A1c <7-8% per ADA + GP context; avoid hyperglycemia >180 (acutely worsens emptying) • PO/SC • continuous
    triggers: diabetic_GP
    ACG 2022 — hyperglycemia acutely worsens gastric emptying; tight control improves symptoms
  • discontinue_offending_meds
    first line
    deprescribing
    Discontinue or substitute opioids, GLP-1 agonists (semaglutide / tirzepatide), anticholinergics, TCAs where possible • PO/SC • one_time
    triggers: drug_induced_or_drug_contributing_GP
    ACG 2022 — drug-induced GP common and reversible
  • hydration_electrolyte_replacement
    first line
    supportive
    PO if tolerated; IV if severe • PO/IV • continuous
    triggers: dehydration, electrolyte_disturbance
    ACG 2022 — common in moderate-severe GP

outpatient playbook — drug actions (6)

  1. 1. dietary modification
    Small frequent low-fat low-fiber meals • PO • meals
    trigger: Confirmed GP (ACG 2022)
    Foundational
  2. 2. metoclopramide (12-week limit)
    rxcui 6915
    5-10 mg PO 30 min AC + bedtime; max 40 mg/day • PO • QID
    trigger: Persistent symptoms after diet/glycemic optimization (ACG 2022)
    First-line prokinetic; 12-wk limit + TD screen
  3. 3. domperidone (FDA IND)
    rxcui 3626
    10 mg PO TID; max 30 mg/day • PO • TID
    trigger: Metoclopramide intolerance / TD risk (ACG 2022)
    Alternative; FDA limited-access
  4. 4. erythromycin (short-term)
    rxcui 4053
    50-250 mg PO TID before meals • PO • TID
    trigger: Other prokinetics unsuitable (ACG 2022)
    Tachyphylaxis ~4 wks limits chronic use
  5. 5. prucalopride (off-label for GP)
    rxcui 2107309
    2 mg PO daily • PO • daily
    trigger: Idiopathic GP refractory (ACG 2022)
    Conditionally recommended
  6. 6. aprepitant for refractory nausea
    rxcui 358255
    80 mg PO daily (continuous in refractory GP) • PO • daily
    trigger: Refractory nausea (ACG 2022)
    NK1 antagonist; conditional recommendation

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Chronic nausea, vomiting, early satiety, post-prandial fullness (≥3 months) (ACG 2022); Unexplained chronic vomiting + diabetes (ACG 2022); 4-hour gastric emptying scintigraphy with >10% retention at 4h (ACG 2022 gold standard).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Gastroparesis** (gi.gastroparesis.core.v1).
Phenotype framing: Distinguish from functional dyspepsia, cyclic vomiting syndrome, cannabinoid hyperemesis, rumination syndrome, anorexia nervosa, mechanical obstruction, SMA syndrome (ACG 2022)
Scope: Chronic gastroparesis: delayed gastric emptying without mechanical obstruction; commonly diabetic, idiopathic, post-surgical, or drug-induced (ACG 2022)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Gastroparesis tiered management — diet + glycemic + prokinetic + antiemetic + endoscopic / surgical (ACG 2022)** — step "Step 1 — Foundational management (all patients)".
1. dietary_modification Small frequent (5-6/day) low-fat low-fiber meals; soft / liquid-blended consistency during flares; chew thoroughly PO meals (lifestyle, first line) — ACG 2022 — dietary modification is first-line for all GP patients
2. optimize_glycemic_control A1c <7-8% per ADA + GP context; avoid hyperglycemia >180 (acutely worsens emptying) PO/SC continuous (lifestyle, first line) — ACG 2022 — hyperglycemia acutely worsens gastric emptying; tight control improves symptoms
3. discontinue_offending_meds Discontinue or substitute opioids, GLP-1 agonists (semaglutide / tirzepatide), anticholinergics, TCAs where possible PO/SC one_time (deprescribing, first line) — ACG 2022 — drug-induced GP common and reversible
4. hydration_electrolyte_replacement PO if tolerated; IV if severe PO/IV continuous (supportive, first line) — ACG 2022 — common in moderate-severe GP

Setting playbook (outpatient) — Confirm GP via 4-hour scintigraphy + EGD; tiered management starting with diet + glycemic + deprescribing; prokinetic short-term; antiemetic; refer for G-POEM / GES if refractory (ACG 2022)
5. dietary modification Small frequent low-fat low-fiber meals PO meals — Confirmed GP (ACG 2022) (Foundational)
6. metoclopramide (12-week limit) 5-10 mg PO 30 min AC + bedtime; max 40 mg/day PO QID — Persistent symptoms after diet/glycemic optimization (ACG 2022) (First-line prokinetic; 12-wk limit + TD screen)
7. domperidone (FDA IND) 10 mg PO TID; max 30 mg/day PO TID — Metoclopramide intolerance / TD risk (ACG 2022) (Alternative; FDA limited-access)
8. erythromycin (short-term) 50-250 mg PO TID before meals PO TID — Other prokinetics unsuitable (ACG 2022) (Tachyphylaxis ~4 wks limits chronic use)
9. prucalopride (off-label for GP) 2 mg PO daily PO daily — Idiopathic GP refractory (ACG 2022) (Conditionally recommended)
10. aprepitant for refractory nausea 80 mg PO daily (continuous in refractory GP) PO daily — Refractory nausea (ACG 2022) (NK1 antagonist; conditional recommendation)

Non-pharmacologic actions:
- Diabetes care optimization + A1c target (ACG 2022)
- Nutrition consult (small frequent meals + supplements) (ACG 2022)
- Smoking cessation (delays emptying) (ACG 2022)
- Cannabinoid avoidance if hyperemesis pattern (ACG 2022)
- Refer for G-POEM if refractory + pyloric dysfunction on EndoFLIP (ACG 2022)
- Refer for gastric electrical stimulation if refractory diabetic GP (ACG 2022)
- Psychiatric / quality-of-life support (ACG 2022)

AVOID / contraindication checks:
- Metoclopramide_FDA_black_box_tardive_dyskinesia_limit_12_weeks (ACG 2022)
- Metoclopramide_avoid_Parkinson_seizure_pheochromocytoma_or_renal_impairment_dose_adjust (ACG 2022)
- Domperidone_QTc_baseline_and_periodic_ECG (ACG 2022)
- Domperidone_US_FDA_limited_access_IND_required (ACG 2022)
- Erythromycin_tachyphylaxis_in_4_weeks_and_QTc_and_drug_interactions (ACG 2022)
- Botulinum_toxin_pyloric_injection_NOT_recommended_routinely (ACG 2022)
- Discontinue_GLP1_agonists_and_opioids_if_drug_induced (ACG 2022)
- Cannabinoid_avoid_may_worsen_in_cannabinoid_hyperemesis (ACG 2022)

Monitoring

Regimen monitoring:
- weight q1 3mo during titration then q6mo (ACG 2022)
- GCSI symptom score q3 6mo (ACG 2022)
- A1c q3mo in diabetic GP (ACG 2022)
- QTc baseline and periodically on prokinetic (ACG 2022)
- tardive dyskinesia screen every visit on metoclopramide (ACG 2022)
- renal function for metoclopramide dose adjustment (ACG 2022)
- repeat scintigraphy only if treatment response unclear (ACG 2022)
- nutritional status albumin prealbumin if weight loss (ACG 2022)

Setting (outpatient) monitoring:
- Weight + GCSI q3-6 mo (ACG 2022)
- A1c q3 mo in DM-GP (ACG 2022)
- TD screening on metoclopramide every visit (ACG 2022)
- QTc periodically on prokinetic (ACG 2022)
- Repeat scintigraphy only if response unclear (ACG 2022)

Follow-up plan: 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)
- Close-out criterion: long-term plan documented

Monitoring phase: 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)

Disposition

Current setting: outpatient — Confirm GP via 4-hour scintigraphy + EGD; tiered management starting with diet + glycemic + deprescribing; prokinetic short-term; antiemetic; refer for G-POEM / GES if refractory (ACG 2022)

Disposition criteria:
- Continue outpatient if stable + improving (ACG 2022)
- Refractory: refer for G-POEM / GES / nutrition support (ACG 2022)

Escalation triggers (move to higher acuity):
- Severe dehydration or electrolyte disturbance → ED / inpatient (ACG 2022)
- >10% weight loss → nutrition + consider enteral feeding (ACG 2022)
- Refractory disease → G-POEM / GES evaluation (ACG 2022)
- Suspected tardive dyskinesia → discontinue metoclopramide + neurology (ACG 2022)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Severe vomiting with dehydration, hypokalemic hypochloremic metabolic alkalosis, or AKI (ACG 2022)
- [SEVERE] New oral / facial / limb dyskinesia on metoclopramide (ACG 2022 FDA black-box)
- [SEVERE] Weight loss >10% baseline, albumin <3.0, BMI <18 (ACG 2022)

Citations

- ACG 2022 Clinical Guideline: Gastroparesis (Camilleri M et al, Am J Gastroenterol 2022) [PMID:35926490](https://pubmed.ncbi.nlm.nih.gov/35926490/)
- Cited evidence (PMID 36397928) [PMID:36397928](https://pubmed.ncbi.nlm.nih.gov/36397928/)

Last reconciled with current guidelines: 2026-05-26.
References
  • ACG 2022 Clinical Guideline: Gastroparesis (Camilleri M et al, Am J Gastroenterol 2022) — PMID:35926490
  • Cited evidence (PMID 36397928) — PMID:36397928