When it comes to diagnosing gastrointestinal disorders, gastroparesis poses a formidable challenge for both patients and health care providers.

Gastroparesis is defined as delayed stomach emptying in the absence of any obstruction, but a closer look reveals a convoluted landscape where misdiagnoses abound and treatment pathways may lead patients down a perilous slope of invasive procedures.

In a recent Gastroenterology editorial, Dr. Eamonn Quigley, chief of Gastroenterology at Houston Methodist, discusses the complexity of symptoms and inconsistent gastric emptying studies. He calls for a more precise definition of gastroparesis and cautions against therapeutic fixation on gastric emptying acceleration.

"The first hurdle lies in the non-specific nature of symptoms," Dr. Quigley stated. "Nausea, vomiting and abdominal discomfort are commonly associated with delayed gastric emptying, but they also occur in many other gastrointestinal conditions such as ulcers, gastritis, reflux and irritable bowel syndrome."

The challenge is to discern whether these symptoms truly stem from gastroparesis or if they are a result of another underlying issue.

Compounding this diagnostic conundrum is the variability in how gastric emptying is measured. Dr. Quigley points to improper techniques, such as truncated testing periods and overlooking medication influences on stomach emptying speed, as frequent occurrences. Consequently, patients may receive an inaccurate diagnosis, leading to inappropriate treatments and potentially unnecessary procedures.

"Although properly conducted gastric emptying tests are useful, they should not be the sole arbiter of a gastroparesis diagnosis," Dr. Quigley said. "Providers should also explore alternative factors contributing to symptoms, including disorders of the brain-gut axis, sensitivity issues in the stomach and neurological conditions. These influences often go unnoticed when the focus is solely on stomach motility."

Moreover, Dr. Quigley cautions against the slippery slope that ensues once the gastroparesis label is affixed to a patient. Standard treatments aimed at accelerating stomach emptying may prove ineffective or exacerbate symptoms. Drastic measures like gastric stimulators and surgical interventions become options, potentially diverting attention from the root cause.

Addressing the pharmaceutical landscape, Dr. Quigley acknowledges several limitations in drug development for the condition. The lack of specific biomarkers, coupled with symptom variability, has led to disappointing outcomes. Several effective drugs have been taken off the market due to serious side effects ranging from neurological conditions to fatal arrhythmias.

In light of these challenges, Dr. Quigley advocates for a meticulous diagnostic approach guided by the following tips:

• Be sure to correctly interpret the patient's symptoms. Carefully delineate the impact that the symptoms are having on the patient in terms of their nutrition, their quality of life, their daily activities.
• Be very attentive to the presence of factors outside of the stomach that might play a role in their symptoms. It could be a neurological problem, a connective tissue disorder, a drug side effect or a brain/gut disorder such as anxiety, depression or an eating disorder.
• Don't forget that all diseases of the stomach can cause similar symptoms, and it could be ulcer disease, cancer, gastritis, functional dyspepsia, or the like.
• By definition, you must exclude any obstruction in the stomach or beyond, which means you need to do an endoscopy and get some imaging studies.
• Finally, at this stage, if you think the clinical scenario fits, do a well-validated and appropriately performed gastric emptying study.
• If there is delayed gastric emptying without a known cause, give the patient a drug to accelerate stomach emptying. If the symptoms improve, that is a good sign that the diagnosis is correct.
• If delayed gastric emptying is not found, or the accelerated stomach emptying drugs don't work, reassess the symptoms, reevaluate the whole clinical scenario and consider other possible diagnoses.

"Gastroparesis isn't a magic bullet answer-for-everything diagnosis, but it also isn't a mystical, mythical unicorn diagnosis," Dr. Quigley concludes. "The truth is somewhere in the middle; we just need to adopt a more nuanced understanding of symptoms and a more comprehensive approach to evaluation in order to make the right call."