Motility, in full.

In adults with chronic idiopathic constipation, the AGA-ACG panel makes 10 GRADE-based pharmacological recommendations, and the strength tier is part of the recommendation. Unqualified as to prior therapy: STRONG recommendation (moderate certainty) for polyethylene glycol; STRONG recommendation (moderate certainty) for bisacodyl or sodium picosulfate, but explicitly qualified as short-term or rescue therapy; CONDITIONAL suggestion for fiber supplementation (low certainty), magnesium oxide (very low certainty), and senna (low certainty). Reserved for patients who do not respond to, fail, or are intolerant of over-the-counter agents: STRONG recommendation (moderate certainty) for linaclotide, plecanatide, and prucalopride; CONDITIONAL suggestion for lubiprostone (low certainty) and lactulose (very low certainty). The guideline states no specific doses, no mandatory ordering algorithm, and no fixed trial duration; it notes only that nonpharmacological therapies 'often represent the initial steps in management' and directs clinicians to shared decision making incorporating patient preference, cost, and availability. The guideline explicitly does not cover anorectal evacuation disorders, referring those to the ACG 2021 benign anorectal guideline.

Scope: AGA 2025 addresses adults with idiopathic or diabetic gastroparesis; it does not issue diabetes-specific graded recommendations, and every one of its 12 recommendations is CONDITIONAL ("we suggest"), with explicit shared-decision-making carve-outs. Diagnosis: the AGA suggests AGAINST a 2-hour (or shorter) gastric emptying study and in favor of a 4-hour study (conditional, low certainty); the 4-hour value must be measured directly, not mathematically extrapolated from earlier time points, and the study should be done off confounders (opioids, GLP-1 receptor agonists, prokinetics) and without hyperglycemia. Pharmacotherapy, FOR: the AGA suggests using metoclopramide over no metoclopramide (conditional, VERY LOW certainty), typically oral or intranasal starting at 5 mg before meals titrated up to 10 mg before meals, noting the FDA black-box tardive dyskinesia warning and 12-week prescribing limit while observing that absolute tardive dyskinesia risk is low (~1 in 17,800 to 1 in 35,000 prescriptions); and suggests using erythromycin over no erythromycin (conditional, VERY LOW certainty), low-dose 100-150 mg orally 30 minutes before meals, with drug holidays (e.g. 3 weeks on, 1 week off) to counter tachyphylaxis. Efficacy of any pharmacologic agent should be reassessed at 4 to 8 weeks to decide on continuation. Pharmacotherapy, AGAINST (all conditional): domperidone (very low certainty; patients valuing improvement in nausea, vomiting and early satiety over adverse events may reasonably elect it where available, and it may suit those with neurologic side effects on metoclopramide or with Parkinson's disease; requires an FDA IND, with baseline potassium, magnesium and QTc monitoring); prucalopride (very low certainty; patients with idiopathic gastroparesis, or with coexisting chronic idiopathic constipation, may reasonably elect it); aprepitant (low certainty; may help when 5-HT3 antagonists such as ondansetron are not helpful); nortriptyline (low certainty; may reasonably be elected by patients with co-occurring irritable bowel syndrome or significant abdominal pain, started low at 10-25 mg and titrated slowly); buspirone (very low certainty; may help predominant early satiety and bloating); and cannabidiol except in the context of a clinical trial (low certainty). Procedures, all AGAINST, all conditional: G-POEM, except for selected patients with medically refractory disease (low certainty), candidates should have gastroparesis on an appropriately performed 4-hour study, generally at least moderate delay (≥20% retention at 4 hours with the EggBeaters meal), at least 6 months of moderate cardinal symptoms, and a prior trial of a prokinetic such as metoclopramide plus at least one antiemetic; intrapyloric botulinum toxin injection in medically refractory gastroparesis (very low certainty), noting retreatment as often as every 3 months and the risk that repeat injection causes pyloric scarring complicating later G-POEM; and gastric electrical stimulation in medically refractory gastroparesis (very low certainty), noting a roughly 7% serious adverse event rate, that patients should be told GES targets nausea and vomiting rather than abdominal pain, and that patients valuing nausea/vomiting improvement over that risk may reasonably select placement. Surgical pyloric intervention: the AGA recommends surgical pyloromyotomy or pyloroplasty ONLY in the context of clinical trials, designated a knowledge gap, with no recommendation for or against. Ungraded general implementation considerations (explicitly not GRADE recommendations): optimize glycemic control in gastroparesis in the setting of diabetes; review and eliminate medications that delay gastric emptying (opioids, GLP-1 receptor agonists); use small-particle, low-fat, low-residue diets before or alongside pharmacotherapy; and use antiemetics as needed (5-HT3 antagonists such as ondansetron, H1 antagonists such as promethazine, D2 antagonists such as prochlorperazine).