Motility, in full.

First exclude emergency/secondary causes (cauda equina/cord compression, fecal impaction with overflow) with a mandatory digital rectal exam, screen for eating disorder before dietary restriction, and classify the subtype (urge, passive, overflow, mixed) since it drives therapy. Work up loose-stool FI for inflammatory, infectious, and bile-acid drivers before labeling idiopathic. Manage with a stepwise ladder: optimize stool consistency (fiber, loperamide, bile-acid sequestrant, or TCA neuromodulator), pelvic floor PT plus biofeedback, skin protection and bridge devices, then escalate to surgical therapy. Prescribe the antimotility/neuromodulator agents with their indications, dosing, and safety limits: loperamide is first-line for loose-stool/urge FI, start low (e.g., 2 mg before meals or as needed) and titrate to stool consistency while staying within the FDA-approved maximum (8 mg/day OTC, 16 mg/day prescription), because the FDA warns that higher-than-recommended doses cause QT prolongation, torsades de pointes, and cardiac arrest; the TCA neuromodulator (e.g., amitriptyline, typically low-dose ~20 mg) is an off-label option reserved for loose-stool/idiopathic FI, and the AGS Beers Criteria recommend avoiding TCAs such as amitriptyline in older adults given their strong anticholinergic burden, sedation, orthostatic hypotension, and fall risk. Per the dedicated ASCRS 2023 fecal-incontinence guideline (updating ASCRS 2007, superseding reliance on ACG's broader 2021 anorectal-disorders guideline as the primary specialty source), sacral neuromodulation is a first-line surgical option for incontinent patients WITH OR WITHOUT a defined anal sphincter defect (conditional recommendation, low-quality evidence), it is not gated on documenting a sphincter defect. Sphincteroplasty remains appropriate for symptomatic patients with a defined external anal sphincter defect; repeat sphincteroplasty after a failed overlapping repair should generally be avoided in favor of other modalities. Antegrade continence enemas are an option before colostomy, which remains last resort.

Per AGA best practice advice: dietary intervention is most appropriate for IBS patients who have insight into meal-related symptoms and are motivated to make dietary changes. Soluble fiber (e.g., psyllium/ispaghula) is efficacious for global IBS symptoms and is a reasonable initial option, most suitable in constipation-predominant IBS; insoluble fiber (wheat bran) is NOT. The low-FODMAP diet is currently the most evidence-based diet intervention for IBS and is delivered as a structured 3-phase protocol, NOT lifelong restriction: (1) restriction of high-FODMAP foods lasting NO MORE than 4-6 weeks, (2) reintroduction of FODMAP foods, and (3) personalization based on reintroduction results. Any specific diet intervention should be attempted for a predetermined length of time; if there is no clinical response, the diet should be ABANDONED and a different diet or therapy tried, rather than continued indefinitely. Refer willing and appropriate patients to a GI registered dietitian nutritionist (RDN) to implement and supervise the diet. Poor candidates for restrictive diet interventions include patients who already consume few culprit foods, those at risk for malnutrition, those who are food insecure, and those with an eating disorder or uncontrolled psychiatric disorder; routine screening for disordered eating/eating disorders by careful dietary history is critical before starting a restrictive diet.

Scope: individuals with suspected or confirmed idiopathic or diabetic gastroparesis, including medically refractory disease. All 12 recommendations are CONDITIONAL ('suggests'), at low or very low certainty of evidence; none are strong. DIAGNOSIS (Rec 1): AGA suggests against a 2-hour (or shorter) gastric emptying study and in favour of a 4-hour study [conditional, low certainty], because patients with normal emptying at 2 hours may be reclassified as delayed at 4 hours. The 4-hour value must be measured directly at 4 hours, not mathematically derived from earlier time points. Testing should be done without confounders: hyperglycaemia and drugs that alter emptying (opioids, GLP-1 receptor agonists, prokinetics). Two meals have well-established normal values: the low-fat Tougas/EggBeaters meal (liquid egg white, bread, jam, water; 250 kcal, 2% fat) and the Mayo Clinic meal (two whole eggs, bread, skim milk; 320 kcal, 30% fat), the latter more thoroughly validated. PHARMACOTHERAPY: AGA suggests USING metoclopramide (Rec 2) and USING erythromycin (Rec 3), each conditional/very low certainty. Metoclopramide, oral tablet/liquid or intranasal, start 5 mg before meals, may increase up to 10 mg before meals; discuss potential side effects before starting (tardive dyskinesia risk noted, absolute risk low; higher risk of adverse events leading to discontinuation in older patients and those on psychotropics); assess efficacy and side effects at 4-8 weeks to decide on continuation, then monitor for the duration of therapy. Patients placing higher value on adverse-event risk and lower value on symptom improvement may reasonably decline it. Erythromycin, low dose (e.g. 100-150 mg by mouth, 30 min before meals) to reduce side effects seen at 250-500 mg; ethylsuccinate oral suspension allows smaller doses since tablets come only in high strengths; prokinetic via motilin agonism with no direct antiemetic effect; tachyphylaxis with prolonged continuous use is managed by drug holidays (e.g. 3 weeks on, 1 week off); cautions include QT prolongation, CYP3A interactions and antibiotic resistance. AGA suggests AGAINST, as first-line therapy, with shared-decision carve-outs, domperidone (Rec 4), prucalopride (Rec 5), aprepitant (Rec 6), nortriptyline (Rec 7.1) and buspirone (Rec 7.2) [conditional; low to very low certainty], and against cannabidiol EXCEPT in the context of a clinical trial (Rec 8, conditional/low certainty). Each carries an explicit shared-decision-making carve-out naming who may still reasonably use it: domperidone for patients who had neurological side effects on metoclopramide or who have movement disorders such as Parkinson's disease (US use requires an FDA expanded-access IND, and the sole US supplier is exiting; obtain baseline potassium, magnesium and ECG QTc, monitor on therapy, reassess at 4-8 weeks); prucalopride particularly in idiopathic gastroparesis (patients with diabetic or connective-tissue-disease-related gastroparesis are less likely to respond) and in those with coexisting chronic idiopathic constipation, noting the depression/suicidality monitoring warning; aprepitant for nausea and vomiting not helped by 5-HT3 antagonists such as ondansetron, recognising it has no effect on gastric motor function; nortriptyline for coexisting IBS or significant abdominal pain, started at low dose and titrated slowly, framed to patients as a peripheral neuromodulator; buspirone for predominant early satiety and bloating. For cannabidiol the panel notes the single positive trial used pharmaceutical-grade Epidiolex, which is not available for clinical use in gastroparesis, that commercial formulations are unregulated and variable in potency, and that THC-containing products raise cannabinoid hyperemesis concern. PROCEDURES (medically refractory disease): AGA suggests against G-POEM EXCEPT for selected patients with medically refractory disease (Rec 9, conditional/low certainty), candidates should have gastroparesis confirmed on an appropriately performed 4-hour gastric emptying study, generally with at least moderate delay (20% retention at 4 hours with the EggBeaters meal), at least six months of moderate cardinal symptoms (nausea, vomiting and/or postprandial fullness), and a prior trial of other treatments including a prokinetic such as metoclopramide plus an antiemetic. AGA suggests against pyloric botulinum toxin injection (Rec 11, conditional/very low certainty), noting that retreatment as often as every 3 months limits cost-effectiveness and that repeat treatment may cause pyloric scarring complicating later G-POEM; patients placing higher value on endoscopic intervention and lower value on chronic medical therapy may reasonably attempt it. AGA suggests against the ROUTINE INITIAL use of gastric electrical stimulation (Rec 12, conditional/very low certainty), reserving it, as with G-POEM, for select patients whose symptoms are refractory to medical therapy; patients placing higher value on potential nausea/vomiting improvement and lower value on the increase in serious adverse events may reasonably select GES, and should be told it aims to improve nausea and vomiting, not abdominal pain. For surgical pyloric interventions (pyloromyotomy or pyloroplasty) AGA makes NO recommendation and designates a knowledge gap, advising use only in the context of clinical trials (Rec 10). NON-GRADED adjuncts appear only as implementation considerations, not recommendations: panel content experts use small-particle, low-fat, low-residue diets before or alongside pharmacotherapy, and as-needed antiemetics (5-HT3 antagonists e.g. ondansetron, H1 antagonists e.g. promethazine, D2 antagonists e.g. prochlorperazine); efficacy of pharmacological interventions is assessed at 4-8 weeks. The guideline does NOT address exclusion of mechanical obstruction, enteral/J-tube nutrition, glycaemic targets, or perioperative GLP-1 RA management, those remain with the supporting documents.

In adults with chronic nausea and/or vomiting (defined as symptoms that persist more than 4 weeks), whether nausea or vomiting occurs alone or together, and including patients in whom early satiety, postprandial fullness or bloating dominate the clinical picture rather than nausea and vomiting themselves (Statement 17), first exclude pharmacological causes: current medications should be reviewed (Statement 4, moderate evidence, 94% agreement). Endocrine and metabolic causes should be excluded (Statement 1, low evidence, 94% agreement) with bloods comprising thyroid assessment (TSH and T4), glucose, creatinine, calcium and phosphate, parathyroid hormone, and blood urea nitrogen. Pregnancy is identified as the commonest endocrinologic cause and must be considered in any woman of childbearing age. Upper endoscopy is NOT positioned by this guideline as a universally mandatory first test; rather, absence of abnormalities at upper endoscopy is a required element of the diagnosis of chronic unexplained nausea (Statement 74), and oesophagogastroduodenoscopy is the recommended starting point specifically where an oesophageal motility disorder is suspected. Oesophageal manometry is recommended ONLY if oesophageal symptoms are present (Statement 15). Where initial investigation for structural, toxic and metabolic disorders is negative, assess for digestive motility and gut-brain interaction disorders. A gastric emptying test is necessary to establish a diagnosis of gastroparesis in patients with unexplained chronic nausea and vomiting (Statement 19, moderate evidence, 91% agreement); acceptable methods are scintigraphy and octanoic acid breath test (Statement 20, moderate evidence, 94% agreement), with an accurate 4-hour measurement and, at best, absence of medications that impact gastric motility (e.g., prokinetics or opioids). For gastroparesis treatment specifically, defer to the AGA 2025 guideline (supporting source): metoclopramide (conditional, low certainty; counsel on the tardive dyskinesia black-box warning) or erythromycin (conditional, very low certainty; tachyphylaxis managed with drug holidays) for initial pharmacologic treatment; conditional recommendations AGAINST first-line use of domperidone, prucalopride, aprepitant, nortriptyline, buspirone, and cannabidiol; conditional recommendations against routine initial use of botulinum toxin injection, G-POEM, and gastric electrical stimulation, reserving the latter for select patients refractory to medical therapy (G-POEM studied in patients with ≥6-12 months of moderate symptoms and ≥20% gastric retention at 4 hours). The AGA panel explicitly notes that a conditional recommendation against an agent does not preclude its use for an individual patient after shared decision-making weighing benefits and harms; no recommendation was issued on surgical pyloric interventions (evidence gap).

Confirm rumination syndrome by Rome IV clinical criteria, persistent or recurrent regurgitation of recently ingested food into the mouth with subsequent spitting or remastication and swallowing, not preceded by retching, with symptoms present for the last 3 months and onset at least 6 months before diagnosis; supportive (non-mandatory) features include effortless post-meal regurgitation within minutes, regurgitation usually not preceded by nausea, and a non-bilious/non-sour (non-acidic) regurgitant, supported when needed by high-resolution manometry-impedance showing abdominal strain with simultaneous gastric pressure rise and retrograde flow. First-line treatment is diaphragmatic breathing therapy, supplemented by behavioral health/gut-directed CBT and management of coexisting anxiety or eating disorder; baclofen 10 mg TID is an off-label option. Red-flag features (weight loss, hematemesis/bilious vomiting, dysphagia) warrant workup for organic disease, and failure of diaphragmatic breathing prompts motility specialist referral.