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Gastroparesis: Time for a Reappraisal?

73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 Iclinical practice, routine investigations (ie, endoscopy, radiology, laboratory testing) fail to identify organic or biochemical abnormalities that readily explain the symptoms. In these patients, disorders of gastrointestinal function (motility or visceral sensitivity) are thought likely to underlie the symptoms. These so-called functional gastrointestinal disorders are highly prevalent, poorly understood and have major individual, health care, and socioeconomic impacts. Measurements of gastrointestinal motility and, to a lesser extent visceral sensitivity, have been used to determine relevant pathophysiologic disturbances in subgroups of this large patient population. Abnormalities of gastrointestinal motility and sensitivity can be observed on tests such as esophageal manometry, acid perfusion tests, gastric emptying scintigraphy, sphincter of Oddi manometry, colonic transit measurements, and anorectal manometry. Some abnormalities identified in this way have gained acceptance as separate diagnostic entities, for example, the “nutcracker esophagus,” slow transit constipation, sphincter of Oddi dysfunction, and gastroparesis. Gastroparesis, which is defined as the presence of delayed gastric emptying in the absence of mechanical obstruction, and associated with symptoms of postprandial fullness, early satiety, nausea, vomiting, and bloating, is probably the most familiar of these entities, having been extensively mentioned in the literature since the 1960s. Gastroparesis can occur in several clinical settings, but the idiopathic and diabetic gastroparesis groups are the most frequent and clinically important ones. In 2009, a joint American Gastroenterological Association/American Neurogastroenterology and Motility Society panel summarized the current knowledge on epidemiology, pathophysiology, diagnosis, and treatment of gastroparesis and identified areas requiring future research. Among the areas of uncertainty, the panel listed the characterization of symptoms in idiopathic versus diabetic gastroparesis, the differentiation between functional dyspepsia with delayed gastric emptying and idiopathic gastroparesis, and the poor relationship between delayed emptying and symptoms. All of these areas of uncertainty questioned the validity of gastric emptying tests in clinical management and therapeutic trials. In 2006, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Gastroparesis Clinical Consortium was initiated, with the aim of increasing knowledge