Opinion Review
Copyright ©The Author(s) 2019.
World J Gastroenterol. Dec 28, 2019; 25(48): 6880-6889
Published online Dec 28, 2019. doi: 10.3748/wjg.v25.i48.6880
Table 1 Synopsis of commonly used prokinetic agents for gastroparesis[7]
Prokinetic agentsMechanismComments/Limitations
ErythromycinMotilin receptor agonistQT interval prolongation
Antibiotic and bacteria resistance
MetoclopromideD2 antagonist (central/peripheral)Extrapyramidal symptoms (e.g., tardive dyskinesia, dystonia). Can not use > 12 wk
5-HT3 antagonistQT interval prolongation
5-HT4 agonistFDA approved for adults
DomperidonePeripheral D2 antagonistQT interval prolongation
Not approved in United States. Only available through IND
BaclofenGABAB receptor agonist that inhibits transient lower esophageal sphincter relaxation. Increases gastric emptyingMuscle weakness, dizziness
Very limited data, as trial was limited to a gastroesophageal reflux patients
Table 2 Alternative therapies for refractory gastroparesis[2,3,19,21,22]
Botulinum ToxinEndoscopic intra-pyloric injection of botulinum toxin to relax the pylorusRequires frequent injections
No improvement in long term symptoms
Enteral tube feedsUnintentional loss of 10 % or more of the body weight during a period of 3-6 mo, Refractory symptomsMechanical complications: Obstruction, displacement, or dislodgement of the tube.
Gastrointestinal complications: formula intolerance, diarrhea, constipation,
Hinders normal lifestyle and quality of life
Gastrostomy tubeMay be used for venting of secretions to decrease vomiting and fullnessPoor choice for feeding due to delayed gastric emptying
PEG-J tubeAllows the patient to vent gastric secretions to decrease/prevent persistent emesis. Provides jejunal feedingsMigration of the J-tube extension into stomach
Pyloric obstruction from J-tube
Jejunostomy tubeStable access for reliable jejunal nutrientCannot vent stomach
Delivery Avoids gastric penetration
Dual G and J tubeTwo sites-one for venting and one for enteral nutritionIncreased risk of leakage, infection Cosmetic issues
Parenteral NutritionIndicated due to intolerance to enteral feedsCentral venous access required.
High risk of line infections
Time consuming, expensive, and intrusive into daily routines
Anesthesia complications
Surgical Options
PyloroplastySurgical procedure used to widen the pylorusRadical approach
Limited success
Surgical and anesthesia complications
GastrectomyAfter failed medical therapy with severe symptomsPalliative approach
Nausea continues to be a problem
High risk of surgical and anesthesia complications.
Not reversible
Table 3 Comparison of pediatric studies on gastric electrical stimulation
Ref.MethodSample SizeDurationFindings
Islam et al[28]Prospective study on children with chronic nausea and vomiting98-42 mo7 of the 9 patients reporting sustained improvement in symptoms and improved quality of life
Islam et al[5]Retrospective review in children less than 18 years with diagnosis of gastroparesis9710 yrA significant reduction in all individual symptoms as well as the total symptom score at 1, 6, 12, and 12 mo. Recurrence of symptoms leading to device removal occurred in 7 cases. Forty-one patients had continued improvement in symptoms for over 12 mo, with a mean follow up of 3.5 years
Lu et al[29]Retrospective review on patients with functional dyspepsia246-8 moSignificant improvements were seen in multiple areas of the PedsQL, including stomach pain/upset, food/drink limits, heartburn/reflux, gas/bloating, patient worry, medication tolerance, and constipation
Teich et al[35]Prospective study on children with chronic nausea and vomiting refractory to medical therapy and met ROME III criteria for functional dyspepsia160.5-23 moSignificant improvement in severity and frequency of vomiting, frequency and severity of nausea. Also showed decrease in dependence on enteral/parenteral nutrition
Elfvin et al[36]Retrospective review on children with nausea and vomiting312-40 dFavorable response to temporary percutaneous gastric electrical stimulation with greater than 50% vomiting reduction
Hyman et al[26]Case report on a 7 years old boy with intractable visceral pain and gastroparesis and failure to thrive137 moReduction in pain, retching and vomiting. Successful initiation of enteral feeds and meeting caloric requirements