{"type":"rich","version":"1.0","provider_name":"Transistor","provider_url":"https://transistor.fm","author_name":"Board Pearls","title":"Chapter 8, Ep 1 of 2: Gastroparesis","html":"<iframe width=\"100%\" height=\"180\" frameborder=\"no\" scrolling=\"no\" seamless src=\"https://share.transistor.fm/e/ff6e2bb4\"></iframe>","width":"100%","height":180,"duration":837,"description":"Gastroparesis is one phenotype with three failure points: the vagus for accommodation and coordination, the interstitial cells of Cajal for rhythm, and smooth muscle for force. Diabetes hits two of the three, surgery hits the vagus, idiopathic disease hits the pacemaker, and drugs mimic the whole picture by slowing the antrum. Four-hour scintigraphy with strict drug holds and controlled glucose anchors the diagnosis, and the favored move is often to stop a drug rather than confirm a disease.\n \nTopics covered\n\nThree-system model of gastric emptying\nDiabetic and idiopathic gastroparesis\nGLP-1 agonists and drug-induced delay\nFour-hour gastric emptying scintigraphy\nPre-test drug holds and glucose control\nProkinetic drugs by mechanism\nAntiemetics and refractory interventions\nEmptying-symptom mismatch\n \n \nKey decisions\n\nDiagnose delayed emptying only with four-hour scintigraphy: more than 10 percent retained at four hours is diagnostic; grade severity as mild 10-15, moderate 15-35, severe over 35 percent.\nConfirm glucose under 200 before testing, hold prokinetics 2-3 days (false negatives), hold opioids, anticholinergics, cannabinoids, and tobacco (false positives); for delayed emptying on a GLP-1 agonist, stop the drug and repeat only if symptoms persist.\nScope first to exclude obstruction, bezoar, or pyloric stenosis before ordering the emptying study, especially in a diabetic with vomiting.\nMetoclopramide is the only approved prokinetic, first-line, capped near 12 weeks for tardive dyskinesia risk; prolactin elevation makes it the favored cause of secondary amenorrhea in a young woman.\nDomperidone needs a baseline ECG and QTc below 450 in men, 470 in women; IV erythromycin is the most effective agent for an acute inpatient flare but oral form fails long-term via tachyphylaxis.\nIntrapyloric botulinum toxin is recommended against and is the favored wrong answer; gastric electrical stimulation helps diabetics with severe vomiting, and G-POEM suits selected refractory...","thumbnail_url":"https://img.transistorcdn.com/-FuAdDBcPDLhEoUmroZKtOBRvuBn_FHPpYlh41hOnU4/rs:fill:0:0:1/w:400/h:400/q:60/mb:500000/aHR0cHM6Ly9pbWct/dXBsb2FkLXByb2R1/Y3Rpb24udHJhbnNp/c3Rvci5mbS9iNzlh/ZTU4Y2MzNWExMjQ5/MjA5OWMwMmI3ZTk5/NGFiZS5wbmc.webp","thumbnail_width":300,"thumbnail_height":300}