Clinical insights into diabetic gastroparesis: gastric scintigraphy-based diagnosis and treatment outcomes

Clinical insights into diabetic gastroparesis: gastric scintigraphy-based diagnosis and treatment outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical insights into diabetic gastroparesis: gastric scintigraphy-based diagnosis and treatment outcomes Mohamed-Naguib Wifi, Mohamed El Sherbiny, Rasha Sobh Mohamed, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6067249/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Sep, 2025 Read the published version in BMC Gastroenterology → Version 1 posted 10 You are reading this latest preprint version Abstract Background Long-standing diabetes mellitus (DM) can lead to macrovascular and microvascular complications including autonomic neuropathy, which disrupts gut motility. Gastroparesis (GP) is defined as delayed gastric emptying of solids (with or without liquids) in the absence of any mechanical obstruction. The gold standard test for the diagnosis of gastroparesis is gastric scintigraphy (GS) using a solid meal. Gastroparesis poses diagnostic and therapeutic challenges, and can significantly impact patients with DM. The purpose of this study is to evaluate the utility of solid gastric scintigraphy in diagnosing gastroparesis, and to assess the outcomes of medical treatment and gastric per-oral endoscopic myotomy (G-POEM) in patients with DM. Patients and Methods From June 2022 to June 2024, all patients visiting the diabetes clinic in Cairo University Hospital for any reason were screened for symptoms of gastroparesis using the gastroparesis cardinal symptom index (GCSI). Symptomatic patients underwent solid gastric scintigraphy. Those diagnosed with GP were treated for three months and refractory cases were offered G-POEM. Results Thirty-two patients with moderate-to-severe symptoms of gastroparesis were the population of this study. Of these, 62.5% had delayed gastric emptying on solid gastric scintigraphy. A GCSI > 23 independently predicted delayed gastric emptying on solid gastric scintigraphy (OR 1.153, 95% CI (1.009 – 1.317), p = 0.036) . 55% of GP patients achieved improvement in symptoms after three months of optimized medical therapy, and two out of four cases had sustained improvement for one year after G-POEM. The responders to medical treatment were significantly older in age, had lower GCSI and greater reduction in hemoglobin A1c (HbA1c) compared to those in refractory group (p = 0.046, 0.012, 0.012 respectively) . Conclusion This study highlighted the role of the GCSI in assessing and monitoring gastroparesis, particularly in resource-limited settings. Diabetic GP differs in clinical presentation and management from other types of GP. Optimizing glycemic control may contribute to symptoms improvement. Patients with higher GCSI can be refractory to medical treatment and may benefit from early referral for alternative interventions such as G-POEM, potentially avoiding prolonged ineffective treatment. Diabetes mellitus Gastric scintigraphy Gastroparesis G-POEM Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Long-standing DM leads to many macrovascular and microvascular complications including autonomic neuropathy which disrupts gut motility. Gut dysmotility in DM occurs via several mechanisms, including destruction of interstitial cells of Cajal (which is the pacemaker of the enteric neuronal plexuses), and reduction of neuronal nitric oxide synthase, leading to gastric dysmotility, pyloric spasm, and eventually delayed gastric emptying [ 1 ]. Gastroparesis is defined as delayed gastric emptying of solids (with or without liquids) after exclusion of mechanical obstruction. Its most frequent symptoms are nausea, vomiting, early satiety, post-prandial fullness, bloating, and abdominal pain [ 2 ]. The GCSI is a validated tool for assessing symptoms of gastroparesis using a 6-point Likert response scale (from 0 to 5). It evaluates the following symptoms in the past two weeks: nausea, retching, vomiting, stomach fullness, inability to finish a meal, excessive fullness, loss of appetite, bloating, and abdominal distension [ 3 ]. The gold standard for diagnosing gastroparesis is gastric scintigraphy which demonstrates delayed gastric emptying of a solid meal [ 4 ]. The wireless motility capsule is an alternative non-invasive test that can assess the motility and transit times for the whole gut, including the stomach, small intestine, and large intestine separately [ 5 ]. Treatment options for GP include dietary modifications, anti-emetics, and proton pump inhibitors (PPIs). Per-oral endoscopic myotomy (POEM), initially developed for achalasia, is a promising new technique for refractory gastroparesis. It offers shorter operative time, shorter post-procedure hospital stay, and fewer adverse events compared to laparoscopic pyloroplasty [ 6 ]. Patients and methods This prospective observational study evaluated the utility of solid gastric scintigraphy in diagnosing gastroparesis, and assessed the outcomes of medical treatment and G-POEM in patients with DM. Inclusion and exclusion criteria Patients aged ≥ 18 years with type 1 or type 2 DM for at least five years were screened for gastroparesis using GCSI at Cairo University Hospital’s diabetes clinic from June 2022 to June 2024. Patients were included if they had a GCSI of ≥ 10 and persistent symptoms for at least one month. Since gastroparesis and neuropathy typically develop over several years in DM, the five-year DM duration criterion was set to reduce the likelihood of including idiopathic or post-viral gastroparesis. Participants were excluded if they had any of the following: history of gastric surgery, organic gastrointestinal disease, malignancy, chronic debilitating diseases, using glucagon-like peptide-1 agonist, neuro-muscular diseases like parkinsonism, scleroderma, and pregnancy. Symptoms assessment Gastroparesis symptoms were assessed using the GCSI, which consists of 9 items rated on a 0–5 Likert scale (0 = no, 1 = very mild, 2 = mild, 3 = moderate, 4 = severe, 5 = very severe). Since a validated Arabic version of the GCSI questionnaire was not available, the English version was verbally translated into Arabic to ensure patient comprehension. Patients completed the GCSI questionnaire by rating the severity of each of the 9 symptoms over the past two weeks: nausea/vomiting subscale (nausea, retching, and vomiting), post-prandial fullness/early satiety subscale (stomach fullness, inability to finish a normal-sized meal for a healthy person, excessive post-prandial fullness, and loss of appetite), and bloating/distention subscale (bloating and visible abdominal distension). Total GCSI was the sum of all 9 items. A GCSI score from 10–19 was considered moderate, and ≥ 20 was considered severe. Average GCSI was calculated by calculating the mean of the three subscales. Clinical evaluation Eligible patients were subjected to a thorough history taking and clinical examination, including: Type and duration of DM. Anti-diabetic medications. DM complications: Peripheral neuropathy: history of tingling, numbness, or hypothesia. Diabetic nephropathy: either microalbuminuria (urinary albumin/creatinine ratio ≥ 30 mg/g or estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73m 2 using chronic kidney disease epidemiology collaboration (CKD-EPI) creatinine 2021 equation. Retinopathy: history of diabetic retinopathy detected by fundus examination. History of previous myocardial infarction, anginal symptoms, cerebrovascular stroke, peripheral vascular disease, and diabetic foot. Comorbidities: hypertension and thyroid disorders. Body mass index (BMI) was calculated as body weight in kilograms (kg) divided by the square of height in meters (m 2 ). BMI between (18.5 and 24.9) kg/m² was considered normal, (25–29.9) kg/m² was considered overweight, and ≥ 30 kg/m² was considered obese. Diabetic dyslipidemia was defined as total cholesterol > 200 mg/dL, low-density lipoprotein (LDL) > 70 mg/dL, or triglycerides > 150 mg/dL. Laboratory tests Blood samples were taken for: HbA1c (%): <7% was considered good control, (7–8.9%) fair control, (9–10.9%) poor control, and ≥ 11% very poor control. TSH, CBC, kidney and liver function tests, urinary albumin/creatinine ratio and lipid profile. Gastric scintigraphy: Eligible patients were invited to undergo solid gastric scintigraphy, but six patients declined the procedure and were excluded. Baseline characteristics of those who declined scintigraphy were not analyzed but their total number was recorded to assess the impact of potential selection bias. Gastric emptying was assessed after ingestion of 300 grams sandwich meal containing 1 mCi of 99m Tc-DTPA-labeled boiled eggs. Any medication affecting gastric motility (prokinetics, opioids, and anticholinergics) was stopped for 48 hours prior to testing. The time activity curve obtained from the geometric mean of gastric counts displayed for all time points was constructed. The gastric emptying half-time (T 1 / 2 ) for a solid meal was computed by interpolation from the observed data. Gastroparesis was defined as delayed gastric emptying (T 1 / 2 ≥90 minutes). The GP group included patients with GP symptoms and delayed gastric emptying, while the GP-like group included patients with GP symptoms and normal gastric emptying. Medical treatment for gastroparesis group All patients in the GP group were subjected to: Dietary modifications (frequent small semisolid meals and low-fat, low-fiber diet), Blood glucose optimization (intensified insulin regimens), PPIs and prokinetics (domperidone 10 mg, three times daily), and Discontinuation of dipeptidyl peptidase-4 inhibitors (DPP-4i)/Metformin combination. Monthly follow-up was conducted to ensure patients compliance, modify insulin regimens (if needed), and monitor the response to treatment. Patients were assessed after three months using HbA1c (%) and GCSI. Gastric scintigraphy was not repeated after treatment, as the primary focus of this study was symptoms improvement rather than changes in gastric scintigraphy parameters. Response to treatment was defined as a ≥ 40% reduction in the total GCSI from the baseline or ≥ 9-point reduction, along with patient-reported satisfaction with symptom improvement. Patients were considered refractory if they had persistent symptoms despite optimized medical therapy for at least three months, including dietary modifications, prokinetic agents, and antiemetics after exclusion of gastric outlet obstruction using gastroduodenoscopy. G-POEM for refractory patients Patients meeting refractory criteria were offered G-POEM, performed by an experienced endoscopist in POEM under general anesthesia and tracheal intubation. G-POEM consisted of four principal steps: 1) submucosal injection followed by mucosal incision 4–5 cm proximal to the pyloric canal, 2) creation of a submucosal tunnel towards a pyloric ring, 3) a complete myotomy 2–3 cm long, 4) closure of the incision with endoscopic clips. Patients were admitted post-procedure until recovery. They were followed up at 3-, 6- and 12-months post-procedure to assess complications and symptoms improvement. Patients in the GP-like group were treated according to guidelines for functional dyspepsia, and they will be followed to assess the potential development of delayed gastric emptying over time. Statistical methods Data were coded and entered using the statistical package for the Social Sciences (SPSS) version 28 (IBM Corp., Armonk, NY, USA). Data was summarized using mean, standard deviation, median, minimum, and maximum in quantitative data and using frequency (count) and relative frequency (percentage) for categorical data. Comparisons between quantitative variables were done using the non-parametric Mann-Whitney test. For comparing categorical data, Chi square (χ2) test was performed. Exact test was used instead when the expected frequency is less than 5. Correlations between quantitative variables were done using Spearman correlation coefficient. Multivariate stepwise logistic regression analysis was done to detect independent predictors of gastroparesis, and response to medical treatment. It was initially conducted by including all significant parameters from the univariate analysis. After stepwise selection (both forward and backward), only one variable remained in the final model. Results Thirty-two patients with moderate-to-severe symptoms of gastroparesis were included in the study. Among them, 20 patients (62.5%) had delayed gastric emptying (GP group) , while 12 patients (37.5%) had normal gastric emptying (GP-like group) . Table 1 presents the demographic, clinical, and laboratory data of the study population. The majority of patients were females (81.3%), with a mean age of 40.59 ± 11.13 years. Type 2 DM was more common (78%, 25 patients), while type 1 DM represented 28% (7 patients). The mean duration of DM was 12.44 ± 5.44 years. There were no significant differences between GP and GP-like groups regarding the age, sex, type of DM, DM treatment or complications, HbA1c (%), smoking status or other comorbidities. Although not statistically significant, diabetic nephropathy was more prevalent in GP group than GP-like group (12 vs 3 cases, p = 0.055) . Table 1 The demographic, clinical, and laboratory data of all study population, GP group, and GP-like group. Variables All population GP group GP-like group P value Mean SD Mean SD Mean SD Age (Y) 40.59 11.13 40.70 11.14 40.42 11.60 0.893 Duration of DM (Y) 12.44 5.44 13.00 5.79 11.50 4.91 0.477 Duration of insulin (Y) 11.28 6.12 12.22 7.12 9.88 4.29 0.305 BMI 30.87 5.95 30.41 6.82 31.63 4.29 0.307 HbA1c (%) 9.35 2.29 9.24 2.04 9.54 2.75 0.985 TSH 2.73 2.32 2.78 2.19 2.64 2.62 0.795 Hb 12.12 1.80 11.77 1.91 12.72 1.49 0.216 TLC 6.47 2.44 6.73 2.88 6.03 1.44 0.899 PLT 280.67 64.23 285.11 72.41 273.00 49.26 0.735 S. Creatinine 0.89 0.41 0.99 0.47 0.73 0.18 0.083 eGFR 100.97 26.69 94.95 29.43 111.00 18.34 0.170 AST 28.76 14.15 31.75 14.79 19.20 5.54 0.032 ALT 22.50 9.46 24.07 10.25 19.14 6.96 0.368 uACR 98.06 83.40 123.60 93.17 55.50 42.04 0.093 TC 208.47 42.42 208.17 45.33 208.92 39.60 0.917 LDL 112.50 44.39 106.79 45.81 122.50 42.82 0.402 HDL 55.86 27.13 48.27 15.67 68.50 38.19 0.181 TG 167.90 117.15 158.28 108.30 182.33 132.94 0.573 SD Standard Deviation, Y Years, BMI Body Mass Index, TLC Total Leukocyte Count, Hb Hemoglobin, PLT Platelet Count, S. Creatinine Serum Creatinine, eGFR Estimated Glomerular Filtration Rate, AST Aspartate Aminotransferase, ALT Alanine Transaminase, uACR Urinary Albumin/Creatinine Ratio, TC Total Cholesterol, LDL Low-Density Lipoprotein, HDL High-Density Lipoprotein, TG Triglycerides. Symptoms of gastroparesis This study found that 12.5% of cases had moderate symptoms, while 87.5% had severe symptoms. The mean duration of symptoms was 41.03 ± 72 months. The mean total GCSI in all study population, GP group , and GP-like group were 26.41 ± 6.91, 28.50 ± 5.77, and 22.92 ± 7.46 respectively. As shown in Table 2 , the dominating symptom in all groups was post-prandial fullness, while bloating/distension subscale was the most dominating subscale. The GP group had significantly more severe symptoms than the GP-like group according to the total GCSI (p = 0.021) and the average GCSI ( p = 0.048) ( Fig. 1 ) . Table 2 Symptoms of GP in all study population, the GP, and the GP-like groups. Symptoms All population GP group GP-like group P value Mean SD Mean SD Mean SD Symptoms Duration (M) 41.03 72.00 53.30 88.43 20.58 19.28 0.366 Total GCSI /45 26.41 6.91 28.50 5.77 22.92 7.46 0.021 Average GCSI /5 2.96 0.85 3.20 0.69 2.55 0.96 0.048 N/V subscale/5 2.25 1.30 2.47 1.35 1.89 1.17 0.255 PPF/ ES subscale/5 3.21 0.91 3.41 0.89 2.88 0.88 0.091 B/D Subscale/5 3.41 1.65 3.73 1.42 2.87 1.92 0.182 Nausea 3.06 1.52 3.05 1.70 3.08 1.24 0.774 Retching 2.00 1.70 2.25 1.71 1.58 1.68 0.307 Vomiting 1.69 1.89 2.10 2.02 1.00 1.48 0.146 Stomach fullness 3.84 1.42 3.95 1.36 3.67 1.56 0.604 Not able to finish a meal 3.22 1.54 3.55 1.28 2.67 1.83 0.170 Excessive post-prandial fullness 3.09 1.65 3.30 1.59 2.75 1.76 0.387 Loss of appetite 2.69 1.75 2.85 1.81 2.42 1.68 0.477 Bloating 3.44 1.68 3.80 1.44 2.83 1.95 0.158 Visible abdominal distension 3.37 1.70 3.65 1.50 2.92 1.98 0.346 SD Standard Deviation, M Months, GCSI Gastroparesis Cardinal Symptom Index, N/V Nausea/ Vomiting, PPF/ES Post-prandial Fullness/Early Satiety, B/D Bloating/Distension. The logistic regression analysis revealed that the total GCSI is an independent predictor of delayed gastric emptying on solid gastric scintigraphy (OR 1.153, 95% CI (1.009 – 1.317), p = 0.036) . A total GCSI greater than 23 demonstrated 80% sensitivity and 66.7% specificity for the delayed gastric emptying (AUC 0.746, p = 0.016, 95% CI 0.545 – 0.947) ( Fig. 2 ). Scintigraphy parameters The mean T 1 / 2 of gastric emptying for all study population, GP group , and GP-like group were 105.21 ± 44.97, 129.78 ± 38.29 and 64.28 ± 15.54 minutes respectively (p = < 0.001) . Figure 3 illustrates delayed gastric emptying (T 1 / 2 : 193 min) compared to normal gastric emptying (T 1 / 2 : 60 min) in solid gastric scintigraphy studies in two different patients with severe symptoms. The correlations between T 1 / 2 of gastric emptying and other variables in the entire study population are shown in Table 3 . Significant positive correlations were found between T 1 / 2 of gastric emptying and serum creatinine, AST, the total GCSI, the average GCSI, nausea/vomiting subscale, and vomiting severity (p = 0.024, 0.006, 0.004, 0.009, 0.033, 0.030 respectively) . A significant negative correlation was observed with hemoglobin levels (p = 0.004) . Table 3 The correlations between T 1 / 2 of gastric emptying and other variables in all study population. Variables T 1 / 2 of gastric emptying Correlation Coefficient P value N Age (Y) 0.023 0.900 32 Duration of DM (Y) 0.216 0.235 32 BMI -0.133- 0.467 32 HbA1c (%) -0.007- 0.970 32 Hb -0.511- 0.004 30 TLC 0.038 0.840 30 PLT -0.063- 0.741 30 S. Creatinine 0.397 0.024 32 eGFR -0.318- 0.076 32 AST 0.578 0.006 21 ALT 0.117 0.604 22 uACR 0.285 0.284 16 TC -0.185- 0.329 30 LDL -0.254- 0.255 22 HDL -0.294- 0.268 16 TG -0.052- 0.786 30 Symptoms Duration (M) 0.184 0.312 32 Total GCSI /45 0.491 0.004 32 Nausea/Vomiting subscale/5 0.378 0.033 32 Post prandial fullness/Early satiety subscale/5 0.197 0.281 32 Bloating/Distension subscale/5 0.319 0.075 32 Nausea 0.192 0.294 32 Retching 0.328 0.067 32 Vomiting 0.384 0.030 32 Stomach fullness -0.009- 0.960 32 Not able to finish a meal 0.195 0.285 32 Excessive post-prandial fullness 0.179 0.328 32 Loss of appetite 0.056 0.760 32 Bloating 0.319 0.075 32 Visible abdominal distension 0.283 0.117 32 N Number, Y Years, DM Diabetes Mellitus, BMI Body Mass Index, Hb Hemoglobin,TLC Total Leukocyte Count, PLT Platelet Count, S. Creatinine Serum Creatinine, eGFR Estimated Glomerular Filtration Rate, AST Aspartate Aminotransferase, ALT Alanine Transaminase, uACR Urinary Albumin/Creatinine Ratio, TC Total Cholesterol, LDL Low-Density Lipoprotein, HDL High-Density Lipoprotein, TG Triglycerides, M Months, GCSI Gastroparesis Cardinal Symptom Index. Response to medical treatment After medical treatment of patients in the GP group for three months, 55% of cases reported improvement of symptoms. A comparison between the responders and refractory groups is shown in Table 4 . Responders were significantly older than those in the refractory group (p = 0.046) and there was a significantly greater HbA1c reduction (%) in the responders’ group compared to the refractory group (p = 0.012) . Responders also had significantly lower total and average GCSI scores (p = 0.012, 0.025 respectively ) compared to the refractory group ( Fig. 4 ). Logistic regression analysis to identify independent predictors of response to medical treatment revealed that the initial total GCSI score was a predictor of the response to medical treatment (OR 0.764, 95% C I 0.57 – 0.977 and p = 0.032) . An initial total GCSI cutoff value of < 25 was found to be 100% specific and 63.6% sensitive for predicting clinical response to medical treatment (AUC 0.828, p < 0.001, 95% CI 0.647 – 1.009) ( Fig. 5 ) . Table 4 Comparison between responders’ and refractory groups. Variables Responders Refractory P value Mean SD Mean SD Age (Y) 46.09 6.11 34.11 12.62 0.046 HbA1c reduction (%) 15.14 17.82 2.29 5.24 0.012 Initial total GCSI /45 25.64 4.59 32.00 5.27 0.012 Initial average GCSI /5 2.89 0.55 3.58 0.67 0.025 Duration of symptoms (M) 54.82 88.06 51.44 94.19 0.766 Duration of DM (Y) 13.73 6.40 12.11 5.16 0.603 Nausea/Vomiting subscale/5 2.03 1.35 3.00 1.20 0.175 Post-prandial fullness/Early satiety subscale/5 3.14 0.96 3.75 0.68 0.152 Bloating/Distension subscale/5 3.50 1.43 4.00 1.44 0.295 Nausea 3.18 1.60 2.89 1.90 0.766 Retching 1.55 1.57 3.11 1.54 0.056 Vomiting 1.36 1.91 3.00 1.87 0.067 Stomach fullness 3.82 1.47 4.11 1.27 0.603 Not able to finish a meal 3.36 1.43 3.78 1.09 0.656 Excessive post-prandial fullness 3.09 1.81 3.56 1.33 0.656 Loss of appetite 2.27 1.90 3.56 1.51 0.152 Bloating 3.64 1.57 4.00 1.32 0.603 Visible abdominal distension 3.36 1.43 4.00 1.58 0.152 SD Standard Deviation, Y Years, GCSI Gastroparesis Cardinal Symptom Index, M Months, DM Diabetes Mellitus. G-POEM group Of the nine refractory cases, only four consented to undergo G-POEM. The mean age of participants was 38.50 ± 11.79 years, consisting of three females and one male, all had type 2 DM with a mean duration of 10.25 ± 3.69 years and fair glycaemic control. Two participants had diabetes-related complications, and the mean BMI was 28.73 ± 1.59 kg/m 2 . The mean initial total GCSI was 32.75 ± 7.8, with nausea and vomiting being the dominating symptoms. The mean T 1 / 2 of gastric emptying was 166.25 ± 59.77 minutes. Two out of four patients achieved sustained clinical improvement one year after the procedure. In one of them T 1 / 2 of gastric emptying showed 25% reduction after 3 months. Among the two patients who did not improve, one showed no change in gastric scintigraphy after 3 months. The mean reduction in the total GCSI in the four cases was 9.5 ± 5 points, and the mean reduction in HbA1c (%) after G-POEM was 1.98 ± 1.4. No complications were reported. Discussion This study included thirty-two patients presented with symptoms suggestive of gastroparesis. Among them, twenty patients (62.5%) had objectively confirmed delayed gastric emptying (GP group) , while twelve patients (37.5%) had normal gastric emptying (GP-like group) . The majority of patients were females (81.3%) with a mean age of 40.59 ± 11.13 years, aligning with the findings of Navas CM et al. ; they reported a predominance of middle-aged females [ 8 ]. In this study, no significant differences were observed between the GP and GP-like groups regarding age, sex, type of DM, DM treatment and complications, HbA1c (%), smoking status, or comorbidities. Although not statistically significant, the GP group had a higher prevalence of diabetic nephropathy than the GP-like group (12 cases vs 3 cases, p = 0.055) . These findings are consistent with Bharucha et al. who reported delayed gastric emptying in 36% of their cohort (46 patients). They found no associations between gastric emptying and demographic features (age, sex, and BMI), smoking status, type and duration of DM, use of insulin, HbA1c (%), or the presence of diabetes-related complications [ 7 ]. Similarly, Navas CM et al. found no correlation between gastric emptying and the referring symptom, duration of DM, HbA1c (%), or diabetes complications, though they observed an association between more severe gastric emptying delay and insulin dependence (p = 0.046) [ 8 ]. Chedid V et al. found that 19.4% of symptomatic patients had delayed gastric emptying. They concluded that gastric emptying is not related to diabetes control nor the duration of diabetes [ 9 ]. In contrast, Izzy M et al. reported an increased incidence of gastroparesis in patients with worse HbA1c (%) [ 10 ]. Additionally, Bharucha et al . found that patients with delayed gastric emptying had longer duration of DM, higher HgbA1c level, and higher prevalence of retinopathy [ 11 ]. This aligns with the findings of Hyett et al. , who also found that patients with GP had a longer duration of DM when compared to patients with GP-like symptoms [ 12 ]. In this study, post-prandial fullness was the dominating symptom, while the most dominating GCSI subscale was bloating/distension. This contrasts with Navas CM et al. , who reported nausea and upper abdominal pain as the most common symptom, followed by vomiting and early satiety [ 8 ]. Similarly, in Chedid V et al. study, the most common presenting symptom was nausea and vomiting [ 9 ]. These discrepancies may be attributed to differences in population characteristics, underlying comorbidities, and potential regional variations in symptom perception and reporting. In this study, significant positive correlations were observed between the T 1 / 2 of gastric emptying and several parameters including serum creatinine, AST, total GCSI, average GCSI, nausea/vomiting subscale, and vomiting severity (p = 0.024, 0.006, 0.004, 0.009, 0.033, 0,030 respectively) . A significant negative correlation was also found between the T 1 / 2 of gastric emptying and hemoglobin levels (p = 0.004). These findings may suggest an association between delayed gastric emptying and the presence of fatty liver and diabetic nephropathy. The inverse relation between hemoglobin levels and the T 1 / 2 of gastric emptying may reflect nutrient deficiencies in gastroparesis patients due to poor food intake. This is supported by Parkman HP et al. study which demonstrated that many patients with gastroparesis consume diets deficient in calories, carbohydrates, proteins, vitamins, and minerals [ 13 ]. In this study, symptoms of GP were significantly more severe in the GP group compared to the GP-like group according to the total GCSI (p = 0.021) and the average GCSI ( p = 0.048) . Logistic regression analysis identified the total GCSI score as an independent predictor of delayed gastric emptying in gastric scintigraphy (OR 1.153, 95% CI (1.009 – 1.317), p = 0.036) . A total GCSI greater than 23 demonstrated a sensitivity of 80% and a specificity 66.7% for identifying delayed gastric emptying (AUC 0.746, p = 0.016, 95% CI 0.545 – 0.947). These findings should be taken with caution given the wide confidence interval and the small sample size. It may not apply universally before validation in larger cohorts. Cassilly DW et al. found that nausea, inability to finish a normal-size adult meal, and post-prandial fullness sub-score were positively correlated to gastric retention at 2 hours (p = 0.09 and p = 0.005, p = 0.01 respectively) . The correlation between the total GCSI and gastric retention was significant at 2 hours (correlation coefficient 0.144, p = 0.03) but not at 4 hours (correlation coefficient 0.040, p = 0.55) . Importantly, their logistic regression showed that none of the GCSI components independently predicted the diagnosis of gastroparesis, leading to the conclusion that the GCSI may not be a reliable predictor of gastroparesis among symptomatic patients [ 14 ]. Several other studies have similarly failed to identify a significant correlation between upper gastrointestinal symptom scores and gastric emptying [ 15 – 20 ]. These variations in results can be explained by the large inter-patient variations and the subjective nature of GCSI symptoms. They also highlight the importance of confirming the diagnosis using gastric scintigraphy. This discrepancy between gastric emptying and symptoms may be attributed to factors such as visceral hypersensitivity or functional dyspepsia, which can present with similar symptoms despite normal scintigraphy findings. The management of gastroparesis is challenging and requires a multi-disciplinary approach. Potential mechanisms of response to medical treatment include: improved gastric motility due to better glycaemic control, neuro-modulatory effects of prokinetic agents, and discontinuation of DPP-4i/metformin combination that may contribute to gastrointestinal symptoms. In our study, 55% of cases responded to a three-month course of medical treatment. Navas CM et al. found that about 40% of cases reported improvement following anti-emetic therapy with domperidone and metoclopramide; however, they didn’t use GCSI to measure severity of symptoms [ 8 ]. In a single-center cohort of 115 cases of GP (16 of whom had DM), domperidone therapy for an average of three months led to improvement in 69 patients (60%), and moderate improvement in 45 patients (39%), as assessed by the Clinical Patient Grading Assessment Scale [ 21 ]. In a study by Parkman HP et al . including 48 GP patients, 81% of patients showed improvement after domperidone therapy [ 22 ]. Another study, which included 262 cases of GP diagnosed by solid GS (32% of whom had DM), assessed symptoms using the GCSI before and after 48 weeks of medical treatment. In this cohort, 15% of patients achieved a ≥ 50% improvement in their GCSI score [ 23 ]. In the current study, responders were significantly older than those in the refractory group (p = 0.046) . This is consistent with findings from Parkman et al ., who observed that patients < 45 years old had a significantly lower clinical response (1.18 ± 1.05; n = 22) compared to patients ≥ 45 years old (1.88 ± 0.80; n = 27; p < 0.05) [ 22 ]. Similarly, Pasricha PJ et al. reported that older age (≥ 50 years) was associated with the best outcome, with an odds ratio for improvement of 3.35 (CI:1.62 – 6.91, p = 0.001) [ 23 ]. These observations may be attributed in part to greater patient satisfaction in older individuals, and the subjective nature of symptom assessment scores. In our study, responders also had significantly lower initial total and average GCSI scores (p = 0.012, p = 0.025 respectively) . This finding contrasts with the study by Pasricha et al ., where higher total GCSI scores were associated with a more favorable response to treatment after 48 weeks (OR = 2.87, CI: 1.57 – 5.23, p = 0.001 ) [ 23 ]. However, this discrepancy may be more apparent than real. In our cohort, consisted exclusively of diabetic GP, severe symptoms likely reflect greater disease burden and treatment resistance. More severe symptoms may be indicative of greater autonomic dysfunction, and significant gastric dysmotility limiting the efficacy of standard medical treatment. This interpretation is further supported by findings from Amjad et al. , where the presence of peripheral neuropathy was associated with treatment failure [ 33 ]. Additionally, the pathophysiological differences between diabetic and idiopathic gastroparesis may explain the divergence in findings between our study and Pasricha et al. ’s, where two-thirds of patients were non-diabetic. It is possible that in idiopathic gastroparesis, symptom severity reflects a component of visceral hypersensitivity, which might respond differently to therapy compared to the predominant motility dysfunction seen in diabetic gastroparesis. These findings have important clinical implications. In diabetic gastroparesis, severe symptoms may indicate a higher likelihood of refractoriness to standard medical therapy. This suggests the need for stratified treatment approaches, where patients presenting with high symptom burdens may require alternative or more aggressive interventions, such as G-POEM to reduce unnecessary prolonged medical treatments in those unlikely to benefit. In our study, a significantly greater HbA1c reduction (%) was reported in the responders’ group than those in the refractory group (p = 0.012) . This underscores the potential role of glycaemic control in the management of gastroparesis and highlights the bi-directional relation between glycemia and gastroparesis. On one hand, gastroparesis worsens hyperglycemia due to poor oral intake and poor adherence to anti-diabetic medications, often due to post-prandial hypoglycemia. On the other hand, hyperglycemia itself has been shown to worsen gastroparesis [ 29 ]. While several studies have explored the impact of glycaemic control on GP severity, their findings have been inconsistent, highlighting the need for large scale studies to investigate this relationship [ 24 – 27 ]. G-POEM is a new promising procedure for the management of refractory GP. According to the American Gastroenterology Association recommendations, G-POEM should be offered to adult patients with refractory gastroparesis who have gastric outlet obstruction been excluded by gastroduodenoscopy, have delayed gastric emptying in a solid gastric scintigraphy, and have moderate-to-severe symptoms preferably with nausea and vomiting as the dominant symptoms [ 5 ]. When performed by an experienced endoscopists, G-POEM is generally safe, and complications are uncommon. However, serious complications have been reported like bleeding, perforation, capno-peritoneum, gastric ulceration and dumping syndrome [ 30 – 32 ]. In the current study, only 4 of the 9 patients in the refractory group consented to undergo G-POEM. Sustained clinical improvement at 1 year was achieved in 2 cases only. While these results are preliminary and based on a small sample, they align with the existing literature. A systematic review assessing the 1-year clinical outcome after G-POEM reported a pooled clinical success rate of 61% (95% CI) and adverse event rate of 8% [ 28 ]. Conclusion The current study highlighted the role of the GCSI in assessing and monitoring gastroparesis, particularly in resource-limited settings. Diabetic GP differs in clinical presentation and management from other types of GP. Optimizing glycemic control may contribute to symptoms improvement. Patients with higher GCSI can be refractory to medical treatment and may benefit from early referral for alternative interventions such as G-POEM, potentially avoiding prolonged ineffective treatment. As this is an exploratory study, larger and well-designed studies are needed to confirm our findings. Recommendations Further larger studies are needed to confirm our findings. Limitations This study has several limitations. First, the study population was drawn from a single diabetes clinic, which may limit the generalizability of the findings. Additionally, symptomatic patients who declined scintigraphy were not included, introducing potential selection bias. The relatively small sample size compared to other studies may also reduce the statistical power, particularly in the logistic regression analysis, making the results exploratory rather than conclusive. Another limitation is that upper endoscopy was not performed in all patients to exclude potential gastric outlet obstruction. Furthermore, blood glucose levels were not measured immediately prior to gastric scintigraphy. Given that hyperglycemia can delay gastric emptying, this could have influenced the gastric emptying parameters. Further studies should incorporate standardized blood glucose monitoring before gastric emptying assessment. The follow-up period was limited to three months, which was sufficient for short-term assessment of symptom response but may not fully capture the fluctuating nature of gastroparesis. Future studies are needed to assess the long-term outcomes and to determine whether patients in the GP-like group eventually develop gastroparesis. Another limitation of this study is the lack of a validated Arabic version of the GCSI questionnaire. While we verbally translated the questionnaire to facilitate patient understanding, the absence of a standardized linguistic and cultural validation process may have affected the consistency of symptom scoring. Future studies should consider using a formally validated Arabic translation to improve the accuracy of patient-reported outcomes. Abbreviations BMI Body Mass Index DPP-4i Di-Peptidyl Peptidase 4 Inhibitors DM Diabetes Mellitus eGFR Estimated Glomerular Filtration Rate GCSI Gastroparesis Cardinal Symptom Index GP Gastroparesis G-POEM Gastric Per-Oral Endoscopic Myotomy GS Gastric Scintigraphy Half-time T 1 / 2 HbA1c Hemoglobin A1c PPIs Proton Pump Inhibitors Declarations Ethical considerations An informed written consent was obtained from all participants prior to this study. The study protocol was revised and accepted by the ethical committee of the Faculty of Medicine, Cairo University (Code: MD-183-2022). Consent for publication Not applicable Data availability All data generated or analyzed during the current study are included in the published article. Competing interests The authors declare that they have no competing interests. Authors’ contributions MNW designed the study, ensured its integrity, and did the final review, AK did gastric scintigraphy, ME designed the methodology, RS helped in writing and editing, SE recruited patients, collected data, and wrote the manuscript. All the authors read, reviewed, and approved the final manuscript. Funding The authors have received no funding for this article. References Sullivan A, Temperley L, Ruban A. Pathophysiology, aetiology and treatment of gastroparesis. Dig Dis Sci. 2020;65(6):1615–31. Zahid SA, Tated R, Mathew M, et al. Diabetic gastroparesis and its emerging therapeutic options: a narrative review of the literature. Cureus. 2023;15(9):e44870. 10.7759/cureus.44870 . Kornum DS, Terkelsen AJ, Bertoli D, et al. Assessment of gastrointestinal autonomic dysfunction: present and future perspectives. J Clin Med. 2021;10(7):1392. Zheng T, Camilleri M. Management of gastroparesis. Gastroenterol Hepatol. 2021;17(11):515. PMID: 35466306; PMCID: PMC9021159. Camilleri M, Kuo B, Nguyen L, et al. ACG clinical guideline: gastroparesis. Official J Am Coll Gastroenterol. 2022;117(8):1197–220. Landreneau JP, Strong AT, El-Hayek K, et al. Laparoscopic pyloroplasty versus endoscopic per-oral pyloromyotomy for the treatment of gastroparesis. Surg Endosc. 2019;33:773–81. Bharucha AE, Camilleri M, Forstrom LA, et al. Relationship between clinical features and gastric emptying disturbances in diabetes mellitus. Clin Endocrinol. 2009;70(3):415–20. Navas CM, Wadas ED, Zbib NH, et al. Gastroparesis and severity of delayed gastric emptying: comparison of patient characteristics, treatments and medication adverse events. Dig Dis Sci. 2021;66:526–34. Chedid V, Brandler J, Vijayvargiya P, et al. Characterization of upper gastrointestinal symptoms, gastric motor functions, and associations in patients with diabetes at a referral center. Official J Am Coll Gastroenterol. 2019;114(1):143–54. Izzy M, Lee M, Johns-Keating K, et al. Glycosylated hemoglobin level may predict the severity of gastroparesis in diabetic patients. Diabetes Res Clin Pract. 2018;135:45–9. Bharucha AE, Batey-Schaefer B, Cleary PA, et al. Delayed gastric emptying is associated with early and long-term hyperglycemia in type 1 diabetes mellitus. Gastroenterology. 2015;149(2):330–9. Hyett B, Martinez FJ, Gill BM, et al. Delayed radionucleotide gastric emptying studies predict morbidity in diabetics with symptoms of gastroparesis. Gastroenterology. 2009;137(2):445–52. Parkman HP, Yates KP, Hasler WL, et al. Dietary intake and nutritional deficiencies in patients with diabetic or idiopathic gastroparesis. Gastroenterology. 2011;141(2):486–98. Cassilly DW, Wang YR, Friedenberg FK, et al. Symptoms of gastroparesis: use of the gastroparesis cardinal symptom index in symptomatic patients referred for gastric emptying scintigraphy. Digestion. 2008;78(2–3):144–51. Jung HK, Locke ⅢGR, Schleck CD, et al. The incidence, prevalence, and outcomes of patients with gastroparesis in Olmsted County, Minnesota, from 1996 to 2006. Gastroenterology. 2009;136(4):1225–33. Lacy BE, Crowell MD, Mathis C, et al. Gastroparesis: quality of life and health care utilization. J Clin Gastroenterol. 2018;52:20–4. Navas CM, Patel NK, Lacy BE. Gastroparesis: medical and therapeutic advances. Dig Dis Sci. 2017;62:2231–40. Abell TL, Camilleri M, Donohoe K, et al. Consensus recommendations for gastric emptying scintigraphy: a joint report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine. J Nucl Med Technol. 2008;36:44–54. Jaffe JK, Paladugu S, Gaughan JP, et al. Characteristics of nausea and its effects on quality of life in diabetic and idiopathic gastroparesis. J Clin Gastroenterol. 2011;45(4):317–21. Dibaise JK, Patel N, Noelting J, et al. The relationship among gastroparetic symptoms, quality of life, and gastric emptying in patients referred for gastric emptying testing. Neurogastroenterology Motil. 2016;28(2):234–42. Schey R, Saadi M, Midani D, et al. Domperidone to treat symptoms of gastroparesis: benefits and side effects from a large single-center cohort. Dig Dis Sci. 2016;61:3545–51. Parkman HP, Jacobs MR, Mishra A, et al. Domperidone treatment for gastroparesis: demographic and pharmacogenetic characterization of clinical efficacy and side-effects. Dig Dis Sci. 2011;56:115–24. Pasricha PJ, Yates KP, Nguyen L, et al. Outcomes and factors associated with reduced symptoms in patients with gastroparesis. Gastroenterology. 2015;149(7):1762–74. Reddy S, Ramsubeik K, Vega KJ, et al. Do HbA1c levels correlate with delayed gastric emptying in diabetic patients? J Neurogastroenterol Motil. 2010;16(4):414. Bytzer P, Talley NJ, Hammer J, et al. GI symptoms in diabetes mellitus are associated with both poor glycemic control and diabetic complications. Official J Am Coll Gastroenterol. 2002;97(3):604–11. Bharucha AE, Kudva Y, Basu A, et al. Relationship between glycemic control and gastric emptying in poorly controlled type 2 diabetes. Clin Gastroenterol Hepatol. 2015;13:466–76. Halland M, Bharucha AE. Relationship between control of glycemia and gastric emptying disturbances in diabetes mellitus. Clin Gastroenterol Hepatol. 2016;14(7):929–36. Kamal F, Khan MA, Lee-Smith W, et al. Systematic review with meta-analysis: one-year outcomes of gastric peroral endoscopic myotomy for refractory gastroparesis. Aliment Pharmacol Ther. 2022;55:168–77. Jalleh R, Marathe CS, Rayner CK, et al. Diabetic gastroparesis and glycaemic control. Curr Diab Rep. 2019;19:1–11. Mondragón OV, Contreras LF, Velasco GB, et al. Gastric peroral endoscopic myotomy outcomes after 4 years of follow-up in a large cohort of patients with refractory gastroparesis (with video). Gastrointest Endosc. 2022;96(3):487–99. Ichkhanian Y, Vosoughi K, Aghaie Meybodi M, et al. Comprehensive analysis of adverse events associated with gastric peroral endoscopic myotomy: an international multicenter study. Surg endoscopiy. 2021;35:1755–64. Martinek J, Hustak R, Mares J, et al. Endoscopic pyloromyotomy for the treatment of severe and refractory gastroparesis: a pilot, randomised, sham-controlled trial. Gut. 2022;71(11):2170–8. Amjad W, Doycheva I, Kamal F, et al. Clinical predictors of symptom improvement failure in gastroparesis. Annals Gastroenterol. 2022;35(2):119. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 15 Sep, 2025 Read the published version in BMC Gastroenterology → Version 1 posted Editorial decision: Revision requested 18 Apr, 2025 Reviews received at journal 17 Apr, 2025 Reviews received at journal 17 Apr, 2025 Reviews received at journal 08 Apr, 2025 Reviewers agreed at journal 08 Apr, 2025 Reviewers agreed at journal 08 Apr, 2025 Reviewers agreed at journal 08 Apr, 2025 Reviewers invited by journal 08 Apr, 2025 Submission checks completed at journal 07 Apr, 2025 First submitted to journal 07 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6067249","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":440274229,"identity":"f924c8ef-50bb-4341-bb12-99c5e6f62c68","order_by":0,"name":"Mohamed-Naguib Wifi","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Mohamed-Naguib","middleName":"","lastName":"Wifi","suffix":""},{"id":440274230,"identity":"e61ab2d0-a908-4af6-b001-90835881267a","order_by":1,"name":"Mohamed El Sherbiny","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"El","lastName":"Sherbiny","suffix":""},{"id":440274231,"identity":"55d2fbc4-9aa6-4b01-95a6-791a4435dc1b","order_by":2,"name":"Rasha Sobh Mohamed","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Rasha","middleName":"Sobh","lastName":"Mohamed","suffix":""},{"id":440274232,"identity":"1a53fa4b-28f7-49de-b636-ec0c649e1ca9","order_by":3,"name":"Ahmed Kandeel","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Kandeel","suffix":""},{"id":440274233,"identity":"a555d0c2-3f07-47ba-bde3-609ba141afaa","order_by":4,"name":"Sobhi Eid Rizk","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIiWNgGAWjYFACHjaGBAYJxjb25oMPPoBFEojU0sdzLNlwBtFagIBxnkSOmTQPMVrk23uPPXhQYSHbJpFjIG1Tc5iBnz3HgOHDL9xaDM6cSzdIOCNh3MbzrMA459hhBsmeNwaMM/vwaAG6RyKxDYjYkzck5zYcZjC4kWPAzNuDx2EzQFr+AbUwJBgctgRqsQdp+YtHC8MNkJYGoBaOFMNmRpAtQE8xM/zA65c0iYRjIL8cS2bsOZbOI3HmWcHB3gY8DgOGmOSPmjrZ+e3Nx3/8qLGW429P3vjgxx88DkMH4Kg5wNhGghYoIMWWUTAKRsEoGO4AAERZVAVEYcNpAAAAAElFTkSuQmCC","orcid":"","institution":"Cairo University","correspondingAuthor":true,"prefix":"","firstName":"Sobhi","middleName":"Eid","lastName":"Rizk","suffix":""}],"badges":[],"createdAt":"2025-02-19 23:08:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6067249/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6067249/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12876-025-03977-x","type":"published","date":"2025-09-15T15:57:33+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":80297095,"identity":"954d9653-42bf-440a-b65e-d8a0b89db37b","added_by":"auto","created_at":"2025-04-10 08:39:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":41607,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe severity of symptoms according to the total and the average GCSI in GP group versus GP-like group.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-6067249/v1/c0c61983360e91233425cc5c.png"},{"id":80297096,"identity":"dd271bef-53e8-47b2-95a0-1ccfaf75472a","added_by":"auto","created_at":"2025-04-10 08:39:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":124459,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe ROC curve for the total and the average GCSI in predicting the presence of delayed gastric emptying.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-6067249/v1/58f541f5b06f8d991fc7d9a5.png"},{"id":80297109,"identity":"c391bf16-ae87-4fbf-a9be-8567448d46ae","added_by":"auto","created_at":"2025-04-10 08:39:33","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":470747,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDelayed gastric emptying (A) versus normal gastric emptying (B) in solid gastric scintigraphy.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-6067249/v1/ac4ed184a942c19a323fd603.png"},{"id":80297097,"identity":"88ade296-3b10-4f30-bd2c-941b773c136d","added_by":"auto","created_at":"2025-04-10 08:39:33","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":85091,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe correlations between Age, HbA1c reduction (%), initial total GCSI and response to medical treatment.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image4.png","url":"https://assets-eu.researchsquare.com/files/rs-6067249/v1/a5100b6d7cdef65f394cf85a.png"},{"id":80297099,"identity":"0e2f1cf7-7ec7-496e-be4b-d3fe5a7d0686","added_by":"auto","created_at":"2025-04-10 08:39:33","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":85359,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSensitivity and specificity of the initial total and average GCSI in predicting response to medical treatment.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image5.png","url":"https://assets-eu.researchsquare.com/files/rs-6067249/v1/6a328281849f2a283bc91d94.png"},{"id":91889933,"identity":"b1a90f67-3e0d-422d-a569-6db98480311c","added_by":"auto","created_at":"2025-09-22 16:03:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3507448,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6067249/v1/8509b35f-f055-4138-a1eb-a40c975f39e1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical insights into diabetic gastroparesis: gastric scintigraphy-based diagnosis and treatment outcomes","fulltext":[{"header":"Background","content":"\u003cp\u003eLong-standing DM leads to many macrovascular and microvascular complications including autonomic neuropathy which disrupts gut motility. Gut dysmotility in DM occurs via several mechanisms, including destruction of interstitial cells of Cajal (which is the pacemaker of the enteric neuronal plexuses), and reduction of neuronal nitric oxide synthase, leading to gastric dysmotility, pyloric spasm, and eventually delayed gastric emptying [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Gastroparesis is defined as delayed gastric emptying of solids (with or without liquids) after exclusion of mechanical obstruction. Its most frequent symptoms are nausea, vomiting, early satiety, post-prandial fullness, bloating, and abdominal pain [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe GCSI is a validated tool for assessing symptoms of gastroparesis using a 6-point Likert response scale (from 0 to 5). It evaluates the following symptoms in the past two weeks: nausea, retching, vomiting, stomach fullness, inability to finish a meal, excessive fullness, loss of appetite, bloating, and abdominal distension [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe gold standard for diagnosing gastroparesis is gastric scintigraphy which demonstrates delayed gastric emptying of a solid meal [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The wireless motility capsule is an alternative non-invasive test that can assess the motility and transit times for the whole gut, including the stomach, small intestine, and large intestine separately [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTreatment options for GP include dietary modifications, anti-emetics, and proton pump inhibitors (PPIs). Per-oral endoscopic myotomy (POEM), initially developed for achalasia, is a promising new technique for refractory gastroparesis. It offers shorter operative time, shorter post-procedure hospital stay, and fewer adverse events compared to laparoscopic pyloroplasty [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cp\u003eThis prospective observational study evaluated the utility of solid gastric scintigraphy in diagnosing gastroparesis, and assessed the outcomes of medical treatment and G-POEM in patients with DM.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and exclusion criteria\u003c/h2\u003e \u003cp\u003ePatients aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years with type 1 or type 2 DM for at least five years were screened for gastroparesis using GCSI at Cairo University Hospital\u0026rsquo;s diabetes clinic from June 2022 to June 2024. Patients were included if they had a GCSI of \u0026ge;\u0026thinsp;10 and persistent symptoms for at least one month. Since gastroparesis and neuropathy typically develop over several years in DM, the five-year DM duration criterion was set to reduce the likelihood of including idiopathic or post-viral gastroparesis. Participants were excluded if they had any of the following: history of gastric surgery, organic gastrointestinal disease, malignancy, chronic debilitating diseases, using glucagon-like peptide-1 agonist, neuro-muscular diseases like parkinsonism, scleroderma, and pregnancy.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSymptoms assessment\u003c/h3\u003e\n\u003cp\u003eGastroparesis symptoms were assessed using the GCSI, which consists of 9 items rated on a 0\u0026ndash;5 Likert scale (0\u0026thinsp;=\u0026thinsp;no, 1\u0026thinsp;=\u0026thinsp;very mild, 2\u0026thinsp;=\u0026thinsp;mild, 3\u0026thinsp;=\u0026thinsp;moderate, 4\u0026thinsp;=\u0026thinsp;severe, 5\u0026thinsp;=\u0026thinsp;very severe). Since a validated Arabic version of the GCSI questionnaire was not available, the English version was verbally translated into Arabic to ensure patient comprehension. Patients completed the GCSI questionnaire by rating the severity of each of the 9 symptoms over the past two weeks: nausea/vomiting subscale (nausea, retching, and vomiting), post-prandial fullness/early satiety subscale (stomach fullness, inability to finish a normal-sized meal for a healthy person, excessive post-prandial fullness, and loss of appetite), and bloating/distention subscale (bloating and visible abdominal distension). Total GCSI was the sum of all 9 items. A GCSI score from 10\u0026ndash;19 was considered moderate, and \u0026ge;\u0026thinsp;20 was considered severe. Average GCSI was calculated by calculating the mean of the three subscales.\u003c/p\u003e\n\u003ch3\u003eClinical evaluation\u003c/h3\u003e\n\u003cp\u003eEligible patients were subjected to a thorough history taking and clinical examination, including:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eType and duration of DM.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAnti-diabetic medications.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDM complications:\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePeripheral neuropathy: history of tingling, numbness, or hypothesia.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDiabetic nephropathy: either microalbuminuria (urinary albumin/creatinine ratio\u0026thinsp;\u0026ge;\u0026thinsp;30 mg/g or estimated glomerular filtration rate (eGFR)\u0026thinsp;\u0026lt;\u0026thinsp;60 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e using chronic kidney disease epidemiology collaboration (CKD-EPI) creatinine 2021 equation.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eRetinopathy: history of diabetic retinopathy detected by fundus examination.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHistory of previous myocardial infarction, anginal symptoms, cerebrovascular stroke, peripheral vascular disease, and diabetic foot.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eComorbidities: hypertension and thyroid disorders.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eBody mass index (BMI) was calculated as body weight in kilograms (kg) divided by the square of height in meters (m\u003csup\u003e2\u003c/sup\u003e). BMI between (18.5 and 24.9) kg/m\u0026sup2; was considered normal, (25\u0026ndash;29.9) kg/m\u0026sup2; was considered overweight, and \u0026ge;\u0026thinsp;30 kg/m\u0026sup2; was considered obese.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDiabetic dyslipidemia was defined as total cholesterol\u0026thinsp;\u0026gt;\u0026thinsp;200 mg/dL, low-density lipoprotein (LDL)\u0026thinsp;\u0026gt;\u0026thinsp;70 mg/dL, or triglycerides\u0026thinsp;\u0026gt;\u0026thinsp;150 mg/dL.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eLaboratory tests\u003c/h3\u003e\n\u003cp\u003eBlood samples were taken for:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eHbA1c (%): \u0026lt;7% was considered good control, (7\u0026ndash;8.9%) fair control, (9\u0026ndash;10.9%) poor control, and \u0026ge;\u0026thinsp;11% very poor control.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTSH, CBC, kidney and liver function tests, urinary albumin/creatinine ratio and lipid profile.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eGastric scintigraphy:\u003c/h3\u003e\n\u003cp\u003eEligible patients were invited to undergo solid gastric scintigraphy, but six patients declined the procedure and were excluded. Baseline characteristics of those who declined scintigraphy were not analyzed but their total number was recorded to assess the impact of potential selection bias. Gastric emptying was assessed after ingestion of 300 grams sandwich meal containing 1 mCi of 99m Tc-DTPA-labeled boiled eggs. Any medication affecting gastric motility (prokinetics, opioids, and anticholinergics) was stopped for 48 hours prior to testing. The time activity curve obtained from the geometric mean of gastric counts displayed for all time points was constructed. The gastric emptying half-time (T\u003csub\u003e1\u003c/sub\u003e/\u003csub\u003e2\u003c/sub\u003e) for a solid meal was computed by interpolation from the observed data. Gastroparesis was defined as delayed gastric emptying (T\u003csub\u003e1\u003c/sub\u003e/\u003csub\u003e2\u003c/sub\u003e \u0026ge;90 minutes). The \u003cb\u003eGP group\u003c/b\u003e included patients with GP symptoms and delayed gastric emptying, while the \u003cb\u003eGP-like group\u003c/b\u003e included patients with GP symptoms and normal gastric emptying.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eMedical treatment for gastroparesis group\u003c/h2\u003e \u003cp\u003eAll patients in the \u003cb\u003eGP group\u003c/b\u003e were subjected to:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eDietary modifications (frequent small semisolid meals and low-fat, low-fiber diet),\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eBlood glucose optimization (intensified insulin regimens),\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePPIs and prokinetics (domperidone 10 mg, three times daily), and\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDiscontinuation of dipeptidyl peptidase-4 inhibitors (DPP-4i)/Metformin combination.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eMonthly follow-up was conducted to ensure patients compliance, modify insulin regimens (if needed), and monitor the response to treatment. Patients were assessed after three months using HbA1c (%) and GCSI. Gastric scintigraphy was not repeated after treatment, as the primary focus of this study was symptoms improvement rather than changes in gastric scintigraphy parameters. Response to treatment was defined as a\u0026thinsp;\u0026ge;\u0026thinsp;40% reduction in the total GCSI from the baseline or \u0026ge;\u0026thinsp;9-point reduction, along with patient-reported satisfaction with symptom improvement. Patients were considered refractory if they had persistent symptoms despite optimized medical therapy for at least three months, including dietary modifications, prokinetic agents, and antiemetics after exclusion of gastric outlet obstruction using gastroduodenoscopy.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eG-POEM for refractory patients\u003c/h3\u003e\n\u003cp\u003ePatients meeting refractory criteria were offered G-POEM, performed by an experienced endoscopist in POEM under general anesthesia and tracheal intubation. G-POEM consisted of four principal steps: 1) submucosal injection followed by mucosal incision 4\u0026ndash;5 cm proximal to the pyloric canal, 2) creation of a submucosal tunnel towards a pyloric ring, 3) a complete myotomy 2\u0026ndash;3 cm long, 4) closure of the incision with endoscopic clips. Patients were admitted post-procedure until recovery. They were followed up at 3-, 6- and 12-months post-procedure to assess complications and symptoms improvement.\u003c/p\u003e \u003cp\u003ePatients in the \u003cb\u003eGP-like group\u003c/b\u003e were treated according to guidelines for functional dyspepsia, and they will be followed to assess the potential development of delayed gastric emptying over time.\u003c/p\u003e\n\u003ch3\u003eStatistical methods\u003c/h3\u003e\n\u003cp\u003eData were coded and entered using the statistical package for the Social Sciences (SPSS) version 28 (IBM Corp., Armonk, NY, USA). Data was summarized using mean, standard deviation, median, minimum, and maximum in quantitative data and using frequency (count) and relative frequency (percentage) for categorical data. Comparisons between quantitative variables were done using the non-parametric Mann-Whitney test. For comparing categorical data, Chi square (χ2) test was performed. Exact test was used instead when the expected frequency is less than 5. Correlations between quantitative variables were done using Spearman correlation coefficient. Multivariate stepwise logistic regression analysis was done to detect independent predictors of gastroparesis, and response to medical treatment. It was initially conducted by including all significant parameters from the univariate analysis. After stepwise selection (both forward and backward), only one variable remained in the final model.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThirty-two patients with moderate-to-severe symptoms of gastroparesis were included in the study. Among them, 20 patients (62.5%) had delayed gastric emptying \u003cb\u003e(GP group)\u003c/b\u003e, while 12 patients (37.5%) had normal gastric emptying \u003cb\u003e(GP-like group)\u003c/b\u003e. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the demographic, clinical, and laboratory data of the study population. The majority of patients were females (81.3%), with a mean age of 40.59\u0026thinsp;\u0026plusmn;\u0026thinsp;11.13 years. Type 2 DM was more common (78%, 25 patients), while type 1 DM represented 28% (7 patients). The mean duration of DM was 12.44\u0026thinsp;\u0026plusmn;\u0026thinsp;5.44 years. There were no significant differences between \u003cb\u003eGP\u003c/b\u003e and \u003cb\u003eGP-like groups\u003c/b\u003e regarding the age, sex, type of DM, DM treatment or complications, HbA1c (%), smoking status or other comorbidities. Although not statistically significant, diabetic nephropathy was more prevalent in \u003cb\u003eGP group\u003c/b\u003e than \u003cb\u003eGP-like group (12 vs 3 cases, p\u0026thinsp;=\u0026thinsp;0.055)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eThe demographic, clinical, and laboratory data of all study population, GP group, and GP-like group.\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eAll population\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eGP group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eGP-like group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (Y)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e11.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e40.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e11.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.893\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of DM (Y)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e5.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.477\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of insulin (Y)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e6.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.305\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e5.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e31.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.307\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHbA1c (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.985\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTSH\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.795\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHb\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e1.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e12.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.216\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTLC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e2.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.899\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePLT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e280.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e64.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e285.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e72.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e273.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e49.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.735\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eS. Creatinine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.083\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eeGFR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e26.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e94.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e29.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e111.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e18.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.170\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAST\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e14.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e19.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.032\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eALT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e9.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e19.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e6.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.368\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003euACR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e83.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e123.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e93.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e55.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e42.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.093\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e208.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e42.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e208.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e45.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e208.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e39.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.917\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLDL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e112.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e44.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e106.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e45.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e122.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e42.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.402\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHDL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e27.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e68.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e38.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.181\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTG\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e167.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e117.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e158.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e108.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e182.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e132.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.573\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSD Standard Deviation, Y Years, BMI Body Mass Index, TLC Total Leukocyte Count, Hb Hemoglobin, PLT Platelet Count, S. Creatinine Serum Creatinine, eGFR Estimated Glomerular Filtration Rate, AST Aspartate Aminotransferase, ALT Alanine Transaminase, uACR Urinary Albumin/Creatinine Ratio, TC Total Cholesterol, LDL Low-Density Lipoprotein, HDL High-Density Lipoprotein, TG Triglycerides.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSymptoms of gastroparesis\u003c/h2\u003e \u003cp\u003eThis study found that 12.5% of cases had moderate symptoms, while 87.5% had severe symptoms. The mean duration of symptoms was 41.03\u0026thinsp;\u0026plusmn;\u0026thinsp;72 months. The mean total GCSI in all study population, \u003cb\u003eGP group\u003c/b\u003e, and \u003cb\u003eGP-like group\u003c/b\u003e were 26.41\u0026thinsp;\u0026plusmn;\u0026thinsp;6.91, 28.50\u0026thinsp;\u0026plusmn;\u0026thinsp;5.77, and 22.92\u0026thinsp;\u0026plusmn;\u0026thinsp;7.46 respectively. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the dominating symptom in all groups was post-prandial fullness, while bloating/distension subscale was the most dominating subscale. The \u003cb\u003eGP group\u003c/b\u003e had significantly more severe symptoms than the \u003cb\u003eGP-like group\u003c/b\u003e according to the total GCSI \u003cb\u003e(p\u0026thinsp;=\u0026thinsp;0.021)\u003c/b\u003e and the average GCSI (\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.048) (\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSymptoms of GP in all study population, the GP, and the GP-like groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSymptoms\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAll population\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eGP group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eGP-like group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSymptoms Duration (M)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e88.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e20.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e19.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.366\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal GCSI /45\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.021\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAverage GCSI /5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e0.048\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eN/V subscale/5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.255\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePPF/ ES subscale/5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.091\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eB/D Subscale/5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.182\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNausea\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.774\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRetching\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.307\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVomiting\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.146\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStomach fullness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.604\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNot able to finish a meal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.170\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExcessive post-prandial fullness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.387\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLoss of appetite\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.477\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBloating\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.158\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVisible abdominal distension\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.346\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSD Standard Deviation, M Months, GCSI Gastroparesis Cardinal Symptom Index, N/V Nausea/ Vomiting, PPF/ES Post-prandial Fullness/Early Satiety, B/D Bloating/Distension.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eThe logistic regression analysis\u003c/b\u003e revealed that the total GCSI is an independent predictor of delayed gastric emptying on solid gastric scintigraphy \u003cb\u003e(OR 1.153, 95% CI (1.009\u003c/b\u003e\u0026ndash;\u003cb\u003e1.317), p\u0026thinsp;=\u0026thinsp;0.036)\u003c/b\u003e. A total GCSI greater than 23 demonstrated 80% sensitivity and 66.7% specificity for the delayed gastric emptying \u003cb\u003e(AUC 0.746, p\u0026thinsp;=\u0026thinsp;0.016, 95% CI 0.545\u003c/b\u003e\u0026ndash;\u003cb\u003e0.947) (\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eScintigraphy parameters\u003c/h2\u003e \u003cp\u003eThe mean T\u003csub\u003e1\u003c/sub\u003e/\u003csub\u003e2\u003c/sub\u003e of gastric emptying for all study population, \u003cb\u003eGP group\u003c/b\u003e, and \u003cb\u003eGP-like group\u003c/b\u003e were 105.21\u0026thinsp;\u0026plusmn;\u0026thinsp;44.97, 129.78\u0026thinsp;\u0026plusmn;\u0026thinsp;38.29 and 64.28\u0026thinsp;\u0026plusmn;\u0026thinsp;15.54 minutes respectively \u003cb\u003e(p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/b\u003e. Figure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e illustrates delayed gastric emptying (T\u003csub\u003e1\u003c/sub\u003e/\u003csub\u003e2\u003c/sub\u003e: 193 min) compared to normal gastric emptying (T\u003csub\u003e1\u003c/sub\u003e/\u003csub\u003e2\u003c/sub\u003e: 60 min) in solid gastric scintigraphy studies in two different patients with severe symptoms.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe correlations between T\u003csub\u003e1\u003c/sub\u003e/\u003csub\u003e2\u003c/sub\u003e of gastric emptying and other variables in the entire study population are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Significant positive correlations were found between T\u003csub\u003e1\u003c/sub\u003e/\u003csub\u003e2\u003c/sub\u003e of gastric emptying and serum creatinine, AST, the total GCSI, the average GCSI, nausea/vomiting subscale, and vomiting severity \u003cb\u003e(p\u0026thinsp;=\u0026thinsp;0.024, 0.006, 0.004, 0.009, 0.033, 0.030 respectively)\u003c/b\u003e. A significant negative correlation was observed with hemoglobin levels \u003cb\u003e(p\u0026thinsp;=\u0026thinsp;0.004)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe correlations between T\u003csub\u003e1\u003c/sub\u003e/\u003csub\u003e2\u003c/sub\u003e of gastric emptying and other variables in all study population.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eT\u003csub\u003e1\u003c/sub\u003e/\u003csub\u003e2\u003c/sub\u003e of gastric emptying\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCorrelation Coefficient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (Y)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of DM (Y)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.235\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.133-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.467\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHbA1c (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.007-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.970\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHb\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.511-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTLC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.840\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePLT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.063-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.741\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eS. Creatinine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.397\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.024\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eeGFR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.318-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.076\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAST\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.578\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eALT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.604\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003euACR\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.285\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.284\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.185-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.329\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLDL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.254-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.255\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHDL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.294-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTG\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.052-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.786\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSymptoms Duration (M)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.184\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.312\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal GCSI /45\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.491\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNausea/Vomiting subscale/5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.378\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.033\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePost prandial fullness/Early satiety subscale/5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.197\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.281\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBloating/Distension subscale/5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.319\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNausea\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.192\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.294\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRetching\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.328\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.067\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVomiting\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.384\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.030\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStomach fullness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.009-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.960\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNot able to finish a meal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.195\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.285\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExcessive post-prandial fullness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.179\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.328\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLoss of appetite\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.056\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.760\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBloating\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.319\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVisible abdominal distension\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eN Number, Y Years, DM Diabetes Mellitus, BMI Body Mass Index, Hb Hemoglobin,TLC Total Leukocyte Count, PLT Platelet Count, S. Creatinine Serum Creatinine, eGFR Estimated Glomerular Filtration Rate, AST Aspartate Aminotransferase, ALT Alanine Transaminase, uACR Urinary Albumin/Creatinine Ratio, TC Total Cholesterol, LDL Low-Density Lipoprotein, HDL High-Density Lipoprotein, TG Triglycerides, M Months, GCSI Gastroparesis Cardinal Symptom Index.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eResponse to medical treatment\u003c/h2\u003e \u003cp\u003eAfter medical treatment of patients in the \u003cb\u003eGP group\u003c/b\u003e for three months, 55% of cases reported improvement of symptoms. A comparison between the \u003cb\u003eresponders\u003c/b\u003e and \u003cb\u003erefractory groups\u003c/b\u003e is shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. \u003cb\u003eResponders\u003c/b\u003e were significantly older than those in the \u003cb\u003erefractory group (p\u0026thinsp;=\u0026thinsp;0.046)\u003c/b\u003e and there was a significantly greater HbA1c reduction (%) in the \u003cb\u003eresponders\u0026rsquo; group\u003c/b\u003e compared to the \u003cb\u003erefractory group (p\u0026thinsp;=\u0026thinsp;0.012)\u003c/b\u003e. \u003cb\u003eResponders\u003c/b\u003e also had significantly lower total and average GCSI scores \u003cb\u003e(p\u0026thinsp;=\u0026thinsp;0.012, 0.025\u003c/b\u003e respectively\u003cb\u003e)\u003c/b\u003e compared to the \u003cb\u003erefractory group (\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e Logistic regression analysis to identify independent predictors of response to medical treatment revealed that the initial total GCSI score was a predictor of the response to medical treatment \u003cb\u003e(OR 0.764, 95% C I 0.57\u003c/b\u003e\u0026ndash;\u003cb\u003e0.977 and p\u0026thinsp;=\u0026thinsp;0.032)\u003c/b\u003e. An initial total GCSI cutoff value of \u0026lt;\u0026thinsp;25 was found to be 100% specific and 63.6% sensitive for predicting clinical response to medical treatment \u003cb\u003e(AUC 0.828, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, 95% CI 0.647\u003c/b\u003e\u0026ndash;\u003cb\u003e1.009) (\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eComparison between responders\u0026rsquo; and refractory groups.\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eResponders\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eRefractory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (Y)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.046\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHbA1c reduction (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.012\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInitial total GCSI /45\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.012\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInitial average GCSI /5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.025\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of symptoms (M)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e94.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.766\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of DM (Y)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.603\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNausea/Vomiting subscale/5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.175\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePost-prandial fullness/Early satiety subscale/5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.152\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBloating/Distension subscale/5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.295\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNausea\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.766\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRetching\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.056\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVomiting\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.067\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStomach fullness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.603\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNot able to finish a meal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.656\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExcessive post-prandial fullness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.656\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLoss of appetite\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.152\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBloating\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.603\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVisible abdominal distension\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.152\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSD Standard Deviation, Y Years, GCSI Gastroparesis Cardinal Symptom Index, M Months, DM Diabetes Mellitus.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eG-POEM group\u003c/h2\u003e \u003cp\u003eOf the nine refractory cases, only four consented to undergo G-POEM. The mean age of participants was 38.50\u0026thinsp;\u0026plusmn;\u0026thinsp;11.79 years, consisting of three females and one male, all had type 2 DM with a mean duration of 10.25\u0026thinsp;\u0026plusmn;\u0026thinsp;3.69 years and fair glycaemic control. Two participants had diabetes-related complications, and the mean BMI was 28.73\u0026thinsp;\u0026plusmn;\u0026thinsp;1.59 kg/m\u003csup\u003e2\u003c/sup\u003e. The mean initial total GCSI was 32.75\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8, with nausea and vomiting being the dominating symptoms. The mean T\u003csub\u003e1\u003c/sub\u003e/\u003csub\u003e2\u003c/sub\u003e of gastric emptying was 166.25\u0026thinsp;\u0026plusmn;\u0026thinsp;59.77 minutes. Two out of four patients achieved sustained clinical improvement one year after the procedure. In one of them T\u003csub\u003e1\u003c/sub\u003e/\u003csub\u003e2\u003c/sub\u003e of gastric emptying showed 25% reduction after 3 months. Among the two patients who did not improve, one showed no change in gastric scintigraphy after 3 months. The mean reduction in the total GCSI in the four cases was 9.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5 points, and the mean reduction in HbA1c (%) after G-POEM was 1.98\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4. No complications were reported.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study included thirty-two patients presented with symptoms suggestive of gastroparesis. Among them, twenty patients (62.5%) had objectively confirmed delayed gastric emptying \u003cb\u003e(GP group)\u003c/b\u003e, while twelve patients (37.5%) had normal gastric emptying \u003cb\u003e(GP-like group)\u003c/b\u003e. The majority of patients were females (81.3%) with a mean age of 40.59\u0026thinsp;\u0026plusmn;\u0026thinsp;11.13 years, aligning with the findings of \u003cb\u003eNavas CM et al.\u003c/b\u003e; they reported a predominance of middle-aged females [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, no significant differences were observed between the \u003cb\u003eGP\u003c/b\u003e and \u003cb\u003eGP-like groups\u003c/b\u003e regarding age, sex, type of DM, DM treatment and complications, HbA1c (%), smoking status, or comorbidities. Although not statistically significant, the \u003cb\u003eGP group\u003c/b\u003e had a higher prevalence of diabetic nephropathy than the \u003cb\u003eGP-like group (12 cases vs 3 cases, p\u0026thinsp;=\u0026thinsp;0.055)\u003c/b\u003e. These findings are consistent with \u003cb\u003eBharucha et al.\u003c/b\u003e who reported delayed gastric emptying in 36% of their cohort (46 patients). They found no associations between gastric emptying and demographic features (age, sex, and BMI), smoking status, type and duration of DM, use of insulin, HbA1c (%), or the presence of diabetes-related complications [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSimilarly, \u003cb\u003eNavas CM et al.\u003c/b\u003e found no correlation between gastric emptying and the referring symptom, duration of DM, HbA1c (%), or diabetes complications, though they observed an association between more severe gastric emptying delay and insulin dependence \u003cb\u003e(p\u0026thinsp;=\u0026thinsp;0.046)\u003c/b\u003e [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eChedid V et al.\u003c/b\u003e found that 19.4% of symptomatic patients had delayed gastric emptying. They concluded that gastric emptying is not related to diabetes control nor the duration of diabetes [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In contrast, \u003cb\u003eIzzy M et al.\u003c/b\u003e reported an increased incidence of gastroparesis in patients with worse HbA1c (%) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Additionally, \u003cb\u003eBharucha et al\u003c/b\u003e. found that patients with delayed gastric emptying had longer duration of DM, higher HgbA1c level, and higher prevalence of retinopathy [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This aligns with the findings of \u003cb\u003eHyett et al.\u003c/b\u003e, who also found that patients with GP had a longer duration of DM when compared to patients with GP-like symptoms [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, post-prandial fullness was the dominating symptom, while the most dominating GCSI subscale was bloating/distension. This contrasts with \u003cb\u003eNavas CM et al.\u003c/b\u003e, who reported nausea and upper abdominal pain as the most common symptom, followed by vomiting and early satiety [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Similarly, in \u003cb\u003eChedid V et al.\u003c/b\u003e study, the most common presenting symptom was nausea and vomiting [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. These discrepancies may be attributed to differences in population characteristics, underlying comorbidities, and potential regional variations in symptom perception and reporting.\u003c/p\u003e \u003cp\u003eIn this study, significant positive correlations were observed between the T\u003csub\u003e1\u003c/sub\u003e/\u003csub\u003e2\u003c/sub\u003e of gastric emptying and several parameters including serum creatinine, AST, total GCSI, average GCSI, nausea/vomiting subscale, and vomiting severity \u003cb\u003e(p\u0026thinsp;=\u0026thinsp;0.024, 0.006, 0.004, 0.009, 0.033, 0,030 respectively)\u003c/b\u003e. A significant negative correlation was also found between the T\u003csub\u003e1\u003c/sub\u003e/\u003csub\u003e2\u003c/sub\u003e of gastric emptying and hemoglobin levels \u003cb\u003e(p\u0026thinsp;=\u0026thinsp;0.004).\u003c/b\u003e These findings may suggest an association between delayed gastric emptying and the presence of fatty liver and diabetic nephropathy. The inverse relation between hemoglobin levels and the T\u003csub\u003e1\u003c/sub\u003e/\u003csub\u003e2\u003c/sub\u003e of gastric emptying may reflect nutrient deficiencies in gastroparesis patients due to poor food intake. This is supported by \u003cb\u003eParkman HP et al.\u003c/b\u003e study which demonstrated that many patients with gastroparesis consume diets deficient in calories, carbohydrates, proteins, vitamins, and minerals [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, symptoms of GP were significantly more severe in the \u003cb\u003eGP group\u003c/b\u003e compared to the \u003cb\u003eGP-like group\u003c/b\u003e according to the total GCSI \u003cb\u003e(p\u0026thinsp;=\u0026thinsp;0.021)\u003c/b\u003e and the average GCSI (\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.048)\u003c/b\u003e. \u003cb\u003eLogistic regression analysis\u003c/b\u003e identified the total GCSI score as an independent predictor of delayed gastric emptying in gastric scintigraphy \u003cb\u003e(OR 1.153, 95% CI (1.009\u003c/b\u003e\u0026ndash;\u003cb\u003e1.317), p\u0026thinsp;=\u0026thinsp;0.036)\u003c/b\u003e. A total GCSI greater than 23 demonstrated a sensitivity of 80% and a specificity 66.7% for identifying delayed gastric emptying \u003cb\u003e(AUC 0.746, p\u0026thinsp;=\u0026thinsp;0.016, 95% CI 0.545\u003c/b\u003e\u0026ndash;\u003cb\u003e0.947).\u003c/b\u003e These findings should be taken with caution given the wide confidence interval and the small sample size. It may not apply universally before validation in larger cohorts.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCassilly DW et al.\u003c/b\u003e found that nausea, inability to finish a normal-size adult meal, and post-prandial fullness sub-score were positively correlated to gastric retention at 2 hours \u003cb\u003e(p\u0026thinsp;=\u0026thinsp;0.09 and p\u0026thinsp;=\u0026thinsp;0.005, p\u0026thinsp;=\u0026thinsp;0.01 respectively)\u003c/b\u003e. The correlation between the total GCSI and gastric retention was significant at 2 hours \u003cb\u003e(correlation coefficient 0.144, p\u0026thinsp;=\u0026thinsp;0.03)\u003c/b\u003e but not at 4 hours \u003cb\u003e(correlation coefficient 0.040, p\u0026thinsp;=\u0026thinsp;0.55)\u003c/b\u003e. Importantly, their logistic regression showed that none of the GCSI components independently predicted the diagnosis of gastroparesis, leading to the conclusion that the GCSI may not be a reliable predictor of gastroparesis among symptomatic patients [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Several other studies have similarly failed to identify a significant correlation between upper gastrointestinal symptom scores and gastric emptying [\u003cspan additionalcitationids=\"CR16 CR17 CR18 CR19\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. These variations in results can be explained by the large inter-patient variations and the subjective nature of GCSI symptoms. They also highlight the importance of confirming the diagnosis using gastric scintigraphy. This discrepancy between gastric emptying and symptoms may be attributed to factors such as visceral hypersensitivity or functional dyspepsia, which can present with similar symptoms despite normal scintigraphy findings.\u003c/p\u003e \u003cp\u003eThe management of gastroparesis is challenging and requires a multi-disciplinary approach. Potential mechanisms of response to medical treatment include: improved gastric motility due to better glycaemic control, neuro-modulatory effects of prokinetic agents, and discontinuation of DPP-4i/metformin combination that may contribute to gastrointestinal symptoms. In our study, 55% of cases responded to a three-month course of medical treatment. \u003cb\u003eNavas CM et al.\u003c/b\u003e found that about 40% of cases reported improvement following anti-emetic therapy with domperidone and metoclopramide; however, they didn\u0026rsquo;t use GCSI to measure severity of symptoms [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In a single-center cohort of 115 cases of GP (16 of whom had DM), domperidone therapy for an average of three months led to improvement in 69 patients (60%), and moderate improvement in 45 patients (39%), as assessed by the Clinical Patient Grading Assessment Scale [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In a study by \u003cb\u003eParkman HP et al\u003c/b\u003e. including 48 GP patients, 81% of patients showed improvement after domperidone therapy [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Another study, which included 262 cases of GP diagnosed by solid GS (32% of whom had DM), assessed symptoms using the GCSI before and after 48 weeks of medical treatment. In this cohort, 15% of patients achieved a\u0026thinsp;\u0026ge;\u0026thinsp;50% improvement in their GCSI score [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the current study, \u003cb\u003eresponders\u003c/b\u003e were significantly older than those in the \u003cb\u003erefractory group (p\u0026thinsp;=\u0026thinsp;0.046)\u003c/b\u003e. This is consistent with findings from \u003cb\u003eParkman et al\u003c/b\u003e., who observed that patients\u0026thinsp;\u0026lt;\u0026thinsp;45 years old had a significantly lower clinical response \u003cb\u003e(1.18\u0026thinsp;\u0026plusmn;\u0026thinsp;1.05; n\u0026thinsp;=\u0026thinsp;22)\u003c/b\u003e compared to patients\u0026thinsp;\u0026ge;\u0026thinsp;45 years old \u003cb\u003e(1.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.80; n\u0026thinsp;=\u0026thinsp;27; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05)\u003c/b\u003e [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Similarly, \u003cb\u003ePasricha PJ et al.\u003c/b\u003e reported that older age (\u0026ge;\u0026thinsp;50 years) was associated with the best outcome, with an odds ratio for improvement of 3.35 \u003cb\u003e(CI:1.62\u003c/b\u003e\u0026ndash;\u003cb\u003e6.91, p\u0026thinsp;=\u0026thinsp;0.001)\u003c/b\u003e [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. These observations may be attributed in part to greater patient satisfaction in older individuals, and the subjective nature of symptom assessment scores.\u003c/p\u003e \u003cp\u003eIn our study, \u003cb\u003eresponders\u003c/b\u003e also had significantly lower initial total and average GCSI scores \u003cb\u003e(p\u0026thinsp;=\u0026thinsp;0.012, p\u0026thinsp;=\u0026thinsp;0.025 respectively)\u003c/b\u003e. This finding contrasts with the study by \u003cb\u003ePasricha et al\u003c/b\u003e., where higher total GCSI scores were associated with a more favorable response to treatment after 48 weeks \u003cb\u003e(OR\u0026thinsp;=\u0026thinsp;2.87, CI: 1.57\u003c/b\u003e\u0026ndash;\u003cb\u003e5.23, p\u003c/b\u003e\u0026thinsp;\u003cb\u003e=\u003c/b\u003e\u0026thinsp;\u003cb\u003e0.001\u003c/b\u003e) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. However, this discrepancy may be more apparent than real. In our cohort, consisted exclusively of diabetic GP, severe symptoms likely reflect greater disease burden and treatment resistance. More severe symptoms may be indicative of greater autonomic dysfunction, and significant gastric dysmotility limiting the efficacy of standard medical treatment. This interpretation is further supported by findings from \u003cb\u003eAmjad et al.\u003c/b\u003e, where the presence of peripheral neuropathy was associated with treatment failure [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Additionally, the pathophysiological differences between diabetic and idiopathic gastroparesis may explain the divergence in findings between our study and \u003cb\u003ePasricha et al.\u003c/b\u003e\u0026rsquo;s, where two-thirds of patients were non-diabetic. It is possible that in idiopathic gastroparesis, symptom severity reflects a component of visceral hypersensitivity, which might respond differently to therapy compared to the predominant motility dysfunction seen in diabetic gastroparesis. These findings have important clinical implications. In diabetic gastroparesis, severe symptoms may indicate a higher likelihood of refractoriness to standard medical therapy. This suggests the need for stratified treatment approaches, where patients presenting with high symptom burdens may require alternative or more aggressive interventions, such as \u003cb\u003eG-POEM\u003c/b\u003e to reduce unnecessary prolonged medical treatments in those unlikely to benefit.\u003c/p\u003e \u003cp\u003eIn our study, a significantly greater HbA1c reduction (%) was reported in the \u003cb\u003eresponders\u0026rsquo; group\u003c/b\u003e than those in the \u003cb\u003erefractory group (p\u0026thinsp;=\u0026thinsp;0.012)\u003c/b\u003e. This underscores the potential role of glycaemic control in the management of gastroparesis and highlights the bi-directional relation between glycemia and gastroparesis. On one hand, gastroparesis worsens hyperglycemia due to poor oral intake and poor adherence to anti-diabetic medications, often due to post-prandial hypoglycemia. On the other hand, hyperglycemia itself has been shown to worsen gastroparesis [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. While several studies have explored the impact of glycaemic control on GP severity, their findings have been inconsistent, highlighting the need for large scale studies to investigate this relationship [\u003cspan additionalcitationids=\"CR25 CR26\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eG-POEM\u003c/b\u003e is a new promising procedure for the management of refractory GP. According to the American Gastroenterology Association recommendations, G-POEM should be offered to adult patients with refractory gastroparesis who have gastric outlet obstruction been excluded by gastroduodenoscopy, have delayed gastric emptying in a solid gastric scintigraphy, and have moderate-to-severe symptoms preferably with nausea and vomiting as the dominant symptoms [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. When performed by an experienced endoscopists, G-POEM is generally safe, and complications are uncommon. However, serious complications have been reported like bleeding, perforation, capno-peritoneum, gastric ulceration and dumping syndrome [\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In the current study, only 4 of the 9 patients in the \u003cb\u003erefractory group\u003c/b\u003e consented to undergo G-POEM. Sustained clinical improvement at 1 year was achieved in 2 cases only. While these results are preliminary and based on a small sample, they align with the existing literature. A systematic review assessing the 1-year clinical outcome after G-POEM reported a pooled clinical success rate of 61% \u003cb\u003e(95% CI)\u003c/b\u003e and adverse event rate of 8% [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe current study highlighted the role of the GCSI in assessing and monitoring gastroparesis, particularly in resource-limited settings. Diabetic GP differs in clinical presentation and management from other types of GP. Optimizing glycemic control may contribute to symptoms improvement. Patients with higher GCSI can be refractory to medical treatment and may benefit from early referral for alternative interventions such as G-POEM, potentially avoiding prolonged ineffective treatment. As this is an exploratory study, larger and well-designed studies are needed to confirm our findings.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations\u003c/h2\u003e \u003cp\u003eFurther larger studies are needed to confirm our findings.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, the study population was drawn from a single diabetes clinic, which may limit the generalizability of the findings. Additionally, symptomatic patients who declined scintigraphy were not included, introducing potential selection bias. The relatively small sample size compared to other studies may also reduce the statistical power, particularly in the logistic regression analysis, making the results exploratory rather than conclusive. Another limitation is that upper endoscopy was not performed in all patients to exclude potential gastric outlet obstruction. Furthermore, blood glucose levels were not measured immediately prior to gastric scintigraphy. Given that hyperglycemia can delay gastric emptying, this could have influenced the gastric emptying parameters. Further studies should incorporate standardized blood glucose monitoring before gastric emptying assessment. The follow-up period was limited to three months, which was sufficient for short-term assessment of symptom response but may not fully capture the fluctuating nature of gastroparesis. Future studies are needed to assess the long-term outcomes and to determine whether patients in the GP-like group eventually develop gastroparesis. Another limitation of this study is the lack of a validated Arabic version of the GCSI questionnaire. While we verbally translated the questionnaire to facilitate patient understanding, the absence of a standardized linguistic and cultural validation process may have affected the consistency of symptom scoring. Future studies should consider using a formally validated Arabic translation to improve the accuracy of patient-reported outcomes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBMI Body Mass Index\u003c/p\u003e \u003cp\u003eDPP-4i Di-Peptidyl Peptidase 4 Inhibitors\u003c/p\u003e \u003cp\u003eDM Diabetes Mellitus\u003c/p\u003e \u003cp\u003eeGFR Estimated Glomerular Filtration Rate\u003c/p\u003e \u003cp\u003eGCSI Gastroparesis Cardinal Symptom Index\u003c/p\u003e \u003cp\u003eGP Gastroparesis\u003c/p\u003e \u003cp\u003eG-POEM Gastric Per-Oral Endoscopic Myotomy\u003c/p\u003e \u003cp\u003eGS Gastric Scintigraphy\u003c/p\u003e \u003cp\u003eHalf-time T\u003csub\u003e1\u003c/sub\u003e/\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e \u003cp\u003eHbA1c Hemoglobin A1c\u003c/p\u003e \u003cp\u003ePPIs Proton Pump Inhibitors\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn informed written consent was obtained from all participants prior to this study. The study protocol was revised and accepted by the ethical committee of the Faculty of Medicine, Cairo University (Code: MD-183-2022).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during the current study are included in the published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMNW designed the study, ensured its integrity, and did the final review, AK did gastric scintigraphy, ME designed the methodology, RS helped in writing and editing, SE recruited patients, collected data, and wrote the manuscript. All the authors read, reviewed, and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have received no funding for this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSullivan A, Temperley L, Ruban A. Pathophysiology, aetiology and treatment of gastroparesis. Dig Dis Sci. 2020;65(6):1615\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZahid SA, Tated R, Mathew M, et al. Diabetic gastroparesis and its emerging therapeutic options: a narrative review of the literature. 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Dietary intake and nutritional deficiencies in patients with diabetic or idiopathic gastroparesis. Gastroenterology. 2011;141(2):486\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCassilly DW, Wang YR, Friedenberg FK, et al. Symptoms of gastroparesis: use of the gastroparesis cardinal symptom index in symptomatic patients referred for gastric emptying scintigraphy. Digestion. 2008;78(2\u0026ndash;3):144\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJung HK, Locke ⅢGR, Schleck CD, et al. The incidence, prevalence, and outcomes of patients with gastroparesis in Olmsted County, Minnesota, from 1996 to 2006. Gastroenterology. 2009;136(4):1225\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLacy BE, Crowell MD, Mathis C, et al. Gastroparesis: quality of life and health care utilization. J Clin Gastroenterol. 2018;52:20\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNavas CM, Patel NK, Lacy BE. Gastroparesis: medical and therapeutic advances. Dig Dis Sci. 2017;62:2231\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbell TL, Camilleri M, Donohoe K, et al. Consensus recommendations for gastric emptying scintigraphy: a joint report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine. J Nucl Med Technol. 2008;36:44\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJaffe JK, Paladugu S, Gaughan JP, et al. Characteristics of nausea and its effects on quality of life in diabetic and idiopathic gastroparesis. J Clin Gastroenterol. 2011;45(4):317\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDibaise JK, Patel N, Noelting J, et al. 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Gastroenterology. 2015;149(7):1762\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReddy S, Ramsubeik K, Vega KJ, et al. Do HbA1c levels correlate with delayed gastric emptying in diabetic patients? J Neurogastroenterol Motil. 2010;16(4):414.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBytzer P, Talley NJ, Hammer J, et al. GI symptoms in diabetes mellitus are associated with both poor glycemic control and diabetic complications. Official J Am Coll Gastroenterol. 2002;97(3):604\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBharucha AE, Kudva Y, Basu A, et al. Relationship between glycemic control and gastric emptying in poorly controlled type 2 diabetes. Clin Gastroenterol Hepatol. 2015;13:466\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHalland M, Bharucha AE. Relationship between control of glycemia and gastric emptying disturbances in diabetes mellitus. Clin Gastroenterol Hepatol. 2016;14(7):929\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKamal F, Khan MA, Lee-Smith W, et al. Systematic review with meta-analysis: one-year outcomes of gastric peroral endoscopic myotomy for refractory gastroparesis. Aliment Pharmacol Ther. 2022;55:168\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJalleh R, Marathe CS, Rayner CK, et al. Diabetic gastroparesis and glycaemic control. Curr Diab Rep. 2019;19:1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMondrag\u0026oacute;n OV, Contreras LF, Velasco GB, et al. Gastric peroral endoscopic myotomy outcomes after 4 years of follow-up in a large cohort of patients with refractory gastroparesis (with video). Gastrointest Endosc. 2022;96(3):487\u0026ndash;99.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIchkhanian Y, Vosoughi K, Aghaie Meybodi M, et al. Comprehensive analysis of adverse events associated with gastric peroral endoscopic myotomy: an international multicenter study. Surg endoscopiy. 2021;35:1755\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartinek J, Hustak R, Mares J, et al. Endoscopic pyloromyotomy for the treatment of severe and refractory gastroparesis: a pilot, randomised, sham-controlled trial. Gut. 2022;71(11):2170\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmjad W, Doycheva I, Kamal F, et al. Clinical predictors of symptom improvement failure in gastroparesis. Annals Gastroenterol. 2022;35(2):119.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Diabetes mellitus, Gastric scintigraphy, Gastroparesis, G-POEM","lastPublishedDoi":"10.21203/rs.3.rs-6067249/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6067249/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLong-standing diabetes mellitus (DM) can lead to macrovascular and microvascular complications including autonomic neuropathy, which disrupts gut motility. Gastroparesis (GP) is defined as delayed gastric emptying of solids (with or without liquids) in the absence of any mechanical obstruction. The gold standard test for the diagnosis of gastroparesis is gastric scintigraphy (GS) using a solid meal. Gastroparesis poses diagnostic and therapeutic challenges, and can significantly impact patients with DM. The purpose of this study is to evaluate the utility of solid gastric scintigraphy in diagnosing gastroparesis, and to assess the outcomes of medical treatment and gastric per-oral endoscopic myotomy (G-POEM) in patients with DM.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients and Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom June 2022 to June 2024, all patients visiting the diabetes clinic in Cairo University Hospital for any reason were screened for symptoms of gastroparesis using the gastroparesis cardinal symptom index (GCSI). Symptomatic patients underwent solid gastric scintigraphy. Those diagnosed with GP were treated for three months and refractory cases were offered G-POEM.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThirty-two patients with moderate-to-severe symptoms of gastroparesis were the population of this study. Of these, 62.5% had delayed gastric emptying on solid gastric scintigraphy. A GCSI \u0026gt; 23 independently predicted delayed gastric emptying on solid gastric scintigraphy \u003cstrong\u003e(OR 1.153, 95% CI (1.009\u003c/strong\u003e–\u003cstrong\u003e1.317), p = 0.036)\u003c/strong\u003e. 55% of GP patients achieved improvement in symptoms after three months of optimized medical therapy, and two out of four cases had sustained improvement for one year after G-POEM. The responders to medical treatment were significantly older in age, had lower GCSI and greater reduction in hemoglobin A1c (HbA1c) compared to those in refractory group \u003cstrong\u003e(p = 0.046, 0.012, 0.012 respectively)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study highlighted the role of the GCSI in assessing and monitoring gastroparesis, particularly in resource-limited settings. Diabetic GP differs in clinical presentation and management from other types of GP. Optimizing glycemic control may contribute to symptoms improvement. Patients with higher GCSI can be refractory to medical treatment and may benefit from early referral for alternative interventions such as G-POEM, potentially avoiding prolonged ineffective treatment.\u003c/p\u003e","manuscriptTitle":"Clinical insights into diabetic gastroparesis: gastric scintigraphy-based diagnosis and treatment outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-10 08:39:28","doi":"10.21203/rs.3.rs-6067249/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-18T06:24:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-17T23:35:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-17T22:10:41+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-08T19:51:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"78897670715236449363569897070810338244","date":"2025-04-08T19:49:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"239524625611218546635051686845920633923","date":"2025-04-08T08:57:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"144607359600415425685242999655428302310","date":"2025-04-08T08:23:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-08T06:31:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-08T02:45:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Gastroenterology","date":"2025-04-07T22:56:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"26cf04d6-7b52-4709-8ae7-d0d04013fefc","owner":[],"postedDate":"April 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-22T16:02:23+00:00","versionOfRecord":{"articleIdentity":"rs-6067249","link":"https://doi.org/10.1186/s12876-025-03977-x","journal":{"identity":"bmc-gastroenterology","isVorOnly":false,"title":"BMC Gastroenterology"},"publishedOn":"2025-09-15 15:57:33","publishedOnDateReadable":"September 15th, 2025"},"versionCreatedAt":"2025-04-10 08:39:28","video":"","vorDoi":"10.1186/s12876-025-03977-x","vorDoiUrl":"https://doi.org/10.1186/s12876-025-03977-x","workflowStages":[]},"version":"v1","identity":"rs-6067249","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6067249","identity":"rs-6067249","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}