Gastroparesis medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
The medical management of gastroparesis consists of [[Diet (nutrition)|dietary modification]], [[hydration]] and [[nutrition]], optimization of [[glycemic control]] and [[Pharmacotherapy|pharmacotherapy.]] | |||
==Medical Therapy== | ==Medical Therapy== | ||
| Line 11: | Line 11: | ||
The first line management of gastroparesis consists of the following steps:<ref name="pmid25840923">{{cite journal| author=Wytiaz V, Homko C, Duffy F, Schey R, Parkman HP| title=Foods provoking and alleviating symptoms in gastroparesis: patient experiences. | journal=Dig Dis Sci | year= 2015 | volume= 60 | issue= 4 | pages= 1052-8 | pmid=25840923 | doi=10.1007/s10620-015-3651-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25840923 }} </ref><ref name="pmid25600163">{{cite journal| author=Homko CJ, Duffy F, Friedenberg FK, Boden G, Parkman HP| title=Effect of dietary fat and food consistency on gastroparesis symptoms in patients with gastroparesis. | journal=Neurogastroenterol Motil | year= 2015 | volume= 27 | issue= 4 | pages= 501-8 | pmid=25600163 | doi=10.1111/nmo.12519 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25600163 }} </ref><ref name="pmid12680528">{{cite journal| author=Ferdinandis TG, Dissanayake AS, De Silva HJ| title=Effects of carbohydrate meals of varying consistency on gastric myoelectrical activity. | journal=Singapore Med J | year= 2002 | volume= 43 | issue= 11 | pages= 579-82 | pmid=12680528 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12680528 }} </ref><ref name="pmid21735078">{{cite journal| author=Ramzan Z, Duffy F, Gomez J, Fisher RS, Parkman HP| title=Continuous glucose monitoring in gastroparesis. | journal=Dig Dis Sci | year= 2011 | volume= 56 | issue= 9 | pages= 2646-55 | pmid=21735078 | doi=10.1007/s10620-011-1810-z | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21735078 }} </ref> | The first line management of gastroparesis consists of the following steps:<ref name="pmid25840923">{{cite journal| author=Wytiaz V, Homko C, Duffy F, Schey R, Parkman HP| title=Foods provoking and alleviating symptoms in gastroparesis: patient experiences. | journal=Dig Dis Sci | year= 2015 | volume= 60 | issue= 4 | pages= 1052-8 | pmid=25840923 | doi=10.1007/s10620-015-3651-7 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25840923 }} </ref><ref name="pmid25600163">{{cite journal| author=Homko CJ, Duffy F, Friedenberg FK, Boden G, Parkman HP| title=Effect of dietary fat and food consistency on gastroparesis symptoms in patients with gastroparesis. | journal=Neurogastroenterol Motil | year= 2015 | volume= 27 | issue= 4 | pages= 501-8 | pmid=25600163 | doi=10.1111/nmo.12519 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25600163 }} </ref><ref name="pmid12680528">{{cite journal| author=Ferdinandis TG, Dissanayake AS, De Silva HJ| title=Effects of carbohydrate meals of varying consistency on gastric myoelectrical activity. | journal=Singapore Med J | year= 2002 | volume= 43 | issue= 11 | pages= 579-82 | pmid=12680528 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12680528 }} </ref><ref name="pmid21735078">{{cite journal| author=Ramzan Z, Duffy F, Gomez J, Fisher RS, Parkman HP| title=Continuous glucose monitoring in gastroparesis. | journal=Dig Dis Sci | year= 2011 | volume= 56 | issue= 9 | pages= 2646-55 | pmid=21735078 | doi=10.1007/s10620-011-1810-z | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21735078 }} </ref> | ||
*Dietary modification | *Dietary modification | ||
*Hydration and nutrition | *[[Hydration]] and [[nutrition]] | ||
*Optimize glycemic control | *Optimize glycemic control | ||
*Pharmacotherapy | *Pharmacotherapy | ||
| Line 18: | Line 18: | ||
Patients with gastroparesis should be advised the following dietary regimen.<ref name="pmid11151864">{{cite journal| author=Bujanda L| title=The effects of alcohol consumption upon the gastrointestinal tract. | journal=Am J Gastroenterol | year= 2000 | volume= 95 | issue= 12 | pages= 3374-82 | pmid=11151864 | doi=10.1111/j.1572-0241.2000.03347.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11151864 }} </ref><ref name="pmid11908263">{{cite journal| author=Stermer E| title=Alcohol consumption and the gastrointestinal tract. | journal=Isr Med Assoc J | year= 2002 | volume= 4 | issue= 3 | pages= 200-2 | pmid=11908263 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11908263 }} </ref><ref name="pmid2920927">{{cite journal| author=Miller G, Palmer KR, Smith B, Ferrington C, Merrick MV| title=Smoking delays gastric emptying of solids. | journal=Gut | year= 1989 | volume= 30 | issue= 1 | pages= 50-3 | pmid=2920927 | doi= | pmc=1378230 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2920927 }} </ref> | Patients with gastroparesis should be advised the following dietary regimen.<ref name="pmid11151864">{{cite journal| author=Bujanda L| title=The effects of alcohol consumption upon the gastrointestinal tract. | journal=Am J Gastroenterol | year= 2000 | volume= 95 | issue= 12 | pages= 3374-82 | pmid=11151864 | doi=10.1111/j.1572-0241.2000.03347.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11151864 }} </ref><ref name="pmid11908263">{{cite journal| author=Stermer E| title=Alcohol consumption and the gastrointestinal tract. | journal=Isr Med Assoc J | year= 2002 | volume= 4 | issue= 3 | pages= 200-2 | pmid=11908263 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11908263 }} </ref><ref name="pmid2920927">{{cite journal| author=Miller G, Palmer KR, Smith B, Ferrington C, Merrick MV| title=Smoking delays gastric emptying of solids. | journal=Gut | year= 1989 | volume= 30 | issue= 1 | pages= 50-3 | pmid=2920927 | doi= | pmc=1378230 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2920927 }} </ref> | ||
{| class="wikitable" | {| class="wikitable" | ||
!Dietary modification in gastroparesis | ! align="center" style="background:#4479BA; color: #FFFFFF;" + |Dietary modification in gastroparesis | ||
|- | |- | ||
| | | | ||
| Line 25: | Line 25: | ||
* Meals should be homogenized | * Meals should be homogenized | ||
* Avoid carbonated drinks | * Avoid carbonated drinks | ||
* High | * High fiber diet | ||
* Cessation of alcohol and smoking | * Cessation of [[alcohol]] and smoking | ||
|} | |} | ||
===Hydration and nutrition=== | ===Hydration and nutrition=== | ||
*Gastroparesis results in nutrient deficiency and dehydration from reduced oral intake.<ref name="pmid2012043">{{cite journal| author=Ogorek CP, Davidson L, Fisher RS, Krevsky B| title=Idiopathic gastroparesis is associated with a multiplicity of severe dietary deficiencies. | journal=Am J Gastroenterol | year= 1991 | volume= 86 | issue= 4 | pages= 423-8 | pmid=2012043 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2012043 }} </ref><ref name="pmid7942664">{{cite journal| author=Camilleri M| title=Appraisal of medium- and long-term treatment of gastroparesis and chronic intestinal dysmotility. | journal=Am J Gastroenterol | year= 1994 | volume= 89 | issue= 10 | pages= 1769-74 | pmid=7942664 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7942664 }} </ref> | *Gastroparesis results in nutrient deficiency and [[dehydration]] from reduced oral intake.<ref name="pmid2012043">{{cite journal| author=Ogorek CP, Davidson L, Fisher RS, Krevsky B| title=Idiopathic gastroparesis is associated with a multiplicity of severe dietary deficiencies. | journal=Am J Gastroenterol | year= 1991 | volume= 86 | issue= 4 | pages= 423-8 | pmid=2012043 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2012043 }} </ref><ref name="pmid7942664">{{cite journal| author=Camilleri M| title=Appraisal of medium- and long-term treatment of gastroparesis and chronic intestinal dysmotility. | journal=Am J Gastroenterol | year= 1994 | volume= 89 | issue= 10 | pages= 1769-74 | pmid=7942664 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7942664 }} </ref> | ||
*Vitamin supplementation and adequate hydration play an important role in the medical managemnent of gastroparesis to prevent electrolyte imbalance, acidosis and, dehydration. | *[[Vitamin]] supplementation and adequate [[hydration]] play an important role in the medical managemnent of gastroparesis to prevent [[electrolyte imbalance]], [[acidosis]] and, [[dehydration]].<ref name="pmid21684286">{{cite journal| author=Parkman HP, Yates KP, Hasler WL, Nguyan L, Pasricha PJ, Snape WJ et al.| title=Dietary intake and nutritional deficiencies in patients with diabetic or idiopathic gastroparesis. | journal=Gastroenterology | year= 2011 | volume= 141 | issue= 2 | pages= 486-98, 498.e1-7 | pmid=21684286 | doi=10.1053/j.gastro.2011.04.045 | pmc=3499101 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21684286 }} </ref> | ||
*Patients with mild gastroparesis can be fed orally. | *Patients with mild gastroparesis can be fed orally. | ||
*Homogenized meals should be given to patients who are unable to tolerate solids. | *Homogenized meals should be given to patients who are unable to tolerate solids. | ||
===Optimize glycemic control=== | ===Optimize glycemic control=== | ||
*Delayed gastric emptying is most commonly seen in [[diabetics]].<ref name="pmid17314341">{{cite journal| author=Camilleri M| title=Clinical practice. Diabetic gastroparesis. | journal=N Engl J Med | year= 2007 | volume= 356 | issue= 8 | pages= 820-9 | pmid=17314341 | doi=10.1056/NEJMcp062614 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17314341 }} </ref><ref name="pmid25667022">{{cite journal| author=Koch KL, Calles-Escandón J| title=Diabetic gastroparesis. | journal=Gastroenterol Clin North Am | year= 2015 | volume= 44 | issue= 1 | pages= 39-57 | pmid=25667022 | doi=10.1016/j.gtc.2014.11.005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25667022 }} </ref><ref name="pmid10651258">{{cite journal| author=Holzäpfel A, Festa A, Stacher-Janotta G, Bergmann H, Shnawa N, Brannath W et al.| title=Gastric emptying in Type II (non-insulin-dependent) diabetes mellitus before and after therapy readjustment: no influence of actual blood glucose concentration. | journal=Diabetologia | year= 1999 | volume= 42 | issue= 12 | pages= 1410-2 | pmid=10651258 | doi=10.1007/s001250051311 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10651258 }} </ref> | |||
*High glycemic levels are associated with [[delayed gastric emptying]] and eventually leads to gastroparesis. | |||
*Therefore, its important to maintain the [[glucose]] levels in these patients. | |||
The following drugs should be avoided in [[diabetics]] as they [[Delayed gastric emptying|delay gastric emptying]]: | |||
:*[[Incretin]]-based drugs such as pramilintide | |||
:*[[Glucagon-like peptide-1|GLP-1 analoges]] such as [[exenatide]] | |||
===Pharmacotherapy=== | ===Pharmacotherapy=== | ||
Patients who are refractory to the conservative management can be initiated on [[pharmacotherapy]]: | |||
* Prokinteics | |||
*[[Anti-emetic|Anti-emetics]] | |||
*[[Antibiotics]] | |||
===Prokinetics=== | ===Prokinetics=== | ||
*First line drug for the management of gastroparesis is [[metoclopramide]]. | |||
**** Preferred regimen (1): [[metoclopramide]] 5 mg, 15 minutes before meals and at bedtime q8h for '''(contraindications/specific instructions)''' | |||
**** Preferred regimen (2): [[drug name]] 500 mg PO q8h for 14-21 days | |||
**** Preferred regimen (3): [[drug name]] 500 mg q12h for 14-21 days | |||
**** Alternative regimen (1): [[Domperidone]] 10 mg three times daily and increase to 20 mg three times daily with an additional dose at bedtime PO q6h for 7–10 days | |||
**** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days | |||
* | **** Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days | ||
'''Benefits:''' | |||
*Increase the rate of gastric emptying | |||
*Preferably administered in semi-solid to liquid form for better [[digestion]] and [[absorption]] | |||
*Should be given 15-20 minutes before every meal | |||
* | |||
* | |||
* | |||
* | |||
===Feeding Tube=== | ===Feeding Tube=== | ||
If a liquid or pureed diet does not work, you may need surgery to insert a feeding tube. The tube, called a | If a liquid or pureed diet does not work, you may need surgery to insert a feeding tube. The tube, called a jejunostomy, is inserted through the [[skin]] on your abdomen into the small intestine. The [[feeding tube]] bypasses the stomach and places nutrients and medication directly into the [[small intestine]]. These products are then digested and delivered to your bloodstream quickly. You will receive special liquid food to use with the tube. The jejunostomy is used only when gastroparesis is severe or the tube is necessary to stabilize blood glucose levels in people with [[diabetes]]. | ||
===Parenteral Nutrition=== | ===Parenteral Nutrition=== | ||
[[Parenteral nutrition]] refers to delivering nutrients directly into the bloodstream, bypassing the digestive system. The doctor places a thin tube called a [[catheter]] in a | [[Parenteral nutrition]] refers to delivering nutrients directly into the [[bloodstream]], bypassing the digestive system. The doctor places a thin tube called a [[catheter]] in a chest vein, leaving an opening to it outside the skin. For [[feeding]], you attach a bag containing liquid nutrients or medication to the catheter. The fluid enters your [[bloodstream]] through the vein. Your doctor will tell you what type of liquid nutrition to use. | ||
This approach is an alternative to the [[jejunostomy]] tube and is usually a temporary method to get you through a difficult period with gastroparesis. [[Parenteral nutrition]] is used only when gastroparesis is severe and is not helped by other methods. | This approach is an alternative to the [[jejunostomy]] tube and is usually a temporary method to get you through a difficult period with gastroparesis. [[Parenteral nutrition]] is used only when gastroparesis is severe and is not helped by other methods. | ||
===Botulinum Toxin=== | ===Botulinum Toxin=== | ||
Latest revision as of 16:23, 20 February 2018
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Feham Tariq, MD [2]
Overview
The medical management of gastroparesis consists of dietary modification, hydration and nutrition, optimization of glycemic control and pharmacotherapy.
Medical Therapy
The medical therapy of gastroparesis is as follows:
Initial management
The first line management of gastroparesis consists of the following steps:[1][2][3][4]
Dietary modification
Patients with gastroparesis should be advised the following dietary regimen.[5][6][7]
| Dietary modification in gastroparesis |
|---|
|
Hydration and nutrition
- Gastroparesis results in nutrient deficiency and dehydration from reduced oral intake.[8][9]
- Vitamin supplementation and adequate hydration play an important role in the medical managemnent of gastroparesis to prevent electrolyte imbalance, acidosis and, dehydration.[10]
- Patients with mild gastroparesis can be fed orally.
- Homogenized meals should be given to patients who are unable to tolerate solids.
Optimize glycemic control
- Delayed gastric emptying is most commonly seen in diabetics.[11][12][13]
- High glycemic levels are associated with delayed gastric emptying and eventually leads to gastroparesis.
- Therefore, its important to maintain the glucose levels in these patients.
The following drugs should be avoided in diabetics as they delay gastric emptying:
- Incretin-based drugs such as pramilintide
- GLP-1 analoges such as exenatide
Pharmacotherapy
Patients who are refractory to the conservative management can be initiated on pharmacotherapy:
- Prokinteics
Prokinetics
- First line drug for the management of gastroparesis is metoclopramide.
- Preferred regimen (1): metoclopramide 5 mg, 15 minutes before meals and at bedtime q8h for (contraindications/specific instructions)
- Preferred regimen (2): drug name 500 mg PO q8h for 14-21 days
- Preferred regimen (3): drug name 500 mg q12h for 14-21 days
- Alternative regimen (1): Domperidone 10 mg three times daily and increase to 20 mg three times daily with an additional dose at bedtime PO q6h for 7–10 days
- Alternative regimen (2): drug name 500 mg PO q12h for 14–21 days
- Alternative regimen (3): drug name 500 mg PO q6h for 14–21 days
Benefits:
- Increase the rate of gastric emptying
- Preferably administered in semi-solid to liquid form for better digestion and absorption
- Should be given 15-20 minutes before every meal
Feeding Tube
If a liquid or pureed diet does not work, you may need surgery to insert a feeding tube. The tube, called a jejunostomy, is inserted through the skin on your abdomen into the small intestine. The feeding tube bypasses the stomach and places nutrients and medication directly into the small intestine. These products are then digested and delivered to your bloodstream quickly. You will receive special liquid food to use with the tube. The jejunostomy is used only when gastroparesis is severe or the tube is necessary to stabilize blood glucose levels in people with diabetes.
Parenteral Nutrition
Parenteral nutrition refers to delivering nutrients directly into the bloodstream, bypassing the digestive system. The doctor places a thin tube called a catheter in a chest vein, leaving an opening to it outside the skin. For feeding, you attach a bag containing liquid nutrients or medication to the catheter. The fluid enters your bloodstream through the vein. Your doctor will tell you what type of liquid nutrition to use.
This approach is an alternative to the jejunostomy tube and is usually a temporary method to get you through a difficult period with gastroparesis. Parenteral nutrition is used only when gastroparesis is severe and is not helped by other methods.
Botulinum Toxin
The use of botulinum toxin has been associated with improvement in symptoms of gastroparesis in some patients; however, further research on this form of therapy is needed.
References
- ↑ Wytiaz V, Homko C, Duffy F, Schey R, Parkman HP (2015). "Foods provoking and alleviating symptoms in gastroparesis: patient experiences". Dig Dis Sci. 60 (4): 1052–8. doi:10.1007/s10620-015-3651-7. PMID 25840923.
- ↑ Homko CJ, Duffy F, Friedenberg FK, Boden G, Parkman HP (2015). "Effect of dietary fat and food consistency on gastroparesis symptoms in patients with gastroparesis". Neurogastroenterol Motil. 27 (4): 501–8. doi:10.1111/nmo.12519. PMID 25600163.
- ↑ Ferdinandis TG, Dissanayake AS, De Silva HJ (2002). "Effects of carbohydrate meals of varying consistency on gastric myoelectrical activity". Singapore Med J. 43 (11): 579–82. PMID 12680528.
- ↑ Ramzan Z, Duffy F, Gomez J, Fisher RS, Parkman HP (2011). "Continuous glucose monitoring in gastroparesis". Dig Dis Sci. 56 (9): 2646–55. doi:10.1007/s10620-011-1810-z. PMID 21735078.
- ↑ Bujanda L (2000). "The effects of alcohol consumption upon the gastrointestinal tract". Am J Gastroenterol. 95 (12): 3374–82. doi:10.1111/j.1572-0241.2000.03347.x. PMID 11151864.
- ↑ Stermer E (2002). "Alcohol consumption and the gastrointestinal tract". Isr Med Assoc J. 4 (3): 200–2. PMID 11908263.
- ↑ Miller G, Palmer KR, Smith B, Ferrington C, Merrick MV (1989). "Smoking delays gastric emptying of solids". Gut. 30 (1): 50–3. PMC 1378230. PMID 2920927.
- ↑ Ogorek CP, Davidson L, Fisher RS, Krevsky B (1991). "Idiopathic gastroparesis is associated with a multiplicity of severe dietary deficiencies". Am J Gastroenterol. 86 (4): 423–8. PMID 2012043.
- ↑ Camilleri M (1994). "Appraisal of medium- and long-term treatment of gastroparesis and chronic intestinal dysmotility". Am J Gastroenterol. 89 (10): 1769–74. PMID 7942664.
- ↑ Parkman HP, Yates KP, Hasler WL, Nguyan L, Pasricha PJ, Snape WJ; et al. (2011). "Dietary intake and nutritional deficiencies in patients with diabetic or idiopathic gastroparesis". Gastroenterology. 141 (2): 486–98, 498.e1–7. doi:10.1053/j.gastro.2011.04.045. PMC 3499101. PMID 21684286.
- ↑ Camilleri M (2007). "Clinical practice. Diabetic gastroparesis". N Engl J Med. 356 (8): 820–9. doi:10.1056/NEJMcp062614. PMID 17314341.
- ↑ Koch KL, Calles-Escandón J (2015). "Diabetic gastroparesis". Gastroenterol Clin North Am. 44 (1): 39–57. doi:10.1016/j.gtc.2014.11.005. PMID 25667022.
- ↑ Holzäpfel A, Festa A, Stacher-Janotta G, Bergmann H, Shnawa N, Brannath W; et al. (1999). "Gastric emptying in Type II (non-insulin-dependent) diabetes mellitus before and after therapy readjustment: no influence of actual blood glucose concentration". Diabetologia. 42 (12): 1410–2. doi:10.1007/s001250051311. PMID 10651258.