A patient presents with suspicion of gastroparesis Point, what are the expected symptoms and appropriate work and management for this patient?

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gastroparesis diagnosis management

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PMID: 40976635

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I now have comprehensive information from multiple authoritative sources plus the 2025 AGA guideline. Let me compile the full response.

Gastroparesis: Clinical Presentation, Workup, and Management

Definition

Gastroparesis is defined as delayed gastric emptying in the absence of mechanical obstruction, resulting from impaired neuromuscular function of the stomach. It is the second most common sensorimotor disorder of the GI tract, with a prevalence of ~24 per 100,000 persons and a female predominance.

Fischer's Mastery of Surgery, 8th ed., p. 2886

Etiology

Cause	Approximate Incidence
Idiopathic gastroparesis (IGP)	~40%
Diabetic (Type 1 >> Type 2)	~35%
Postsurgical (vagotomy, fundoplication, etc.)	~20%
Other (connective tissue disease, neurological, metabolic)	~5%

Sleisenger & Fordtran's GI and Liver Disease, p. 864

Pathophysiology centers on dysfunction of the interstitial cells of Cajal (ICC), disruption of the vagal/cholinergic axis, and pylorospasm - all of which impair the normal antropyloric pump and coordinated gastric contractility.

Expected Symptoms

Cardinal symptoms:

Nausea (most common, often persistent)
Vomiting - classically occurs 3-4 hours after meals and contains undigested food (vomiting of food eaten the day before is virtually pathognomonic of severe gastroparesis)
Early satiety
Postprandial bloating / abdominal fullness
Abdominal pain

Additional symptoms:

Weight loss (can be substantial in severe cases)
Heartburn / GERD-like symptoms
In diabetics: erratic blood glucose control, unexpected postprandial hypoglycemia (from mismatch between insulin action and delayed nutrient absorption), and recurrent DKA episodes

Physical examination findings:

Succussion splash (retained gastric contents on auscultation while shaking the abdomen)
Signs of peripheral neuropathy (in diabetic gastroparesis)
Signs of malnutrition: cachexia, muscle wasting (in severe disease)
Yamada's Textbook of Gastroenterology, 7th ed., p. 2317
Fischer's Mastery of Surgery, 8th ed., p. 2887

Workup / Diagnostic Evaluation

Step 1 - Rule out mechanical obstruction

Upper endoscopy (EGD) is the first step. It excludes:

Peptic ulcer disease / pyloric stenosis
Gastric or duodenal neoplasm
Peptic strictures
Bezoars (which can form secondary to impaired gastric motility)

Note: Patients with suspected gastroparesis have an increased aspiration risk - plan endoscopy accordingly.

Step 2 - Laboratory studies

CBC, comprehensive metabolic panel
HbA1c (assess glycemic control / identify diabetic etiology)
TSH (hypothyroidism can cause gastroparesis)
Nutritional markers: prealbumin, transferrin
Electrolytes (hypokalemia, hypocalcemia can impair motility)
Exclude metabolic causes: uremia, DKA, hypocalcemia

Step 3 - Exclude offending medications

Review and stop drugs that delay gastric emptying:

Opioids
GLP-1 receptor agonists (e.g., semaglutide, liraglutide) - these delay gastric emptying significantly
Alpha-2 adrenergic agonists, calcium channel blockers, anticholinergics

Step 4 - Confirm delayed gastric emptying (Gold Standard)

4-hour Gastric Emptying Scintigraphy (GES) is the gold standard:

Uses a technetium-99m labeled low-fat, 240 kcal solid egg meal
Scans performed at 0, 1, 2, and 4 hours
Diagnostic threshold: >10% gastric retention at 4 hours
The 2025 AGA Clinical Practice Guideline (PMID 40976635) specifically recommends AGAINST 2-hour testing and recommends FOR 4-hour testing

Severity	Gastric Retention at 4 Hours
Mild	10-15%
Moderate	15-35%
Severe	>35%

Alternative tests (when scintigraphy is unavailable or contraindicated):

Wireless motility capsule (SmartPill)
C-13 octanoic acid breath test
Antroduodenal manometry (for motility assessment)
Electrogastrography (EGG)

Gastroparesis treatment strategy by disease severity

Treatment strategy for gastroparesis stratified by scintigraphic severity. Source: Yamada's Textbook of Gastroenterology, 7th ed.

Management

General measures (all patients):

Discontinue offending medications (opioids, GLP-1 agonists, anticholinergics)
Optimize glycemic control in diabetic patients (hyperglycemia >220 mg/dL itself worsens gastric motility and blunts prokinetic drug response)

Dietary modification:

Small, frequent meals (4-6 per day)
Low fat, low fiber diet
Blenderized/small particle foods as needed in mild-moderate disease; routinely in severe disease
Liquid nutritional supplements for moderate-severe disease

Nutritional support:

Mild: rarely needed
Moderate: caloric liquids, occasionally percutaneous jejunostomy (PEJ) tube
Severe: may require PEJ tube or parenteral nutrition (TPN)

Pharmacological Treatment:

Prokinetics (first-line per 2025 AGA guideline):

Metoclopramide (dopamine D2 antagonist): 5-10 mg PO before meals and at bedtime; the 2025 AGA guideline conditionally recommends its use. Risk of tardive dyskinesia limits long-term use (FDA black box warning; limit to 12 weeks typically); nasal spray formulation available for severe disease
Erythromycin (motilin agonist): 125 mg PO bid; useful short-term, particularly during hospitalizations; tachyphylaxis develops with prolonged use

Note from 2025 AGA guideline (PMID 40976635): Conditional recommendations were issued against domperidone, prucalopride, aprepitant, nortriptyline, buspirone, and cannabidiol as first-line therapies.

Antiemetics (symptom control):

Ondansetron 4-8 mg TID (PO, sublingual, or IV) - most commonly used
Promethazine 12.5-25 mg q4-6h PO/PR/IM
Prochlorperazine 5-10 mg PO/IM
Aprepitant 40-80 mg (NK1 antagonist) - for severe, refractory nausea
Mirtazapine 15-30 mg daily - for severe disease with poor appetite

Symptom modulators (severe/refractory):

Nortriptyline 10-25 mg - neuromodulator; evidence for pain and anorexia, though RCT showed no overall benefit in idiopathic gastroparesis
Acupuncture - may be considered in moderate disease

Procedural / Surgical Options (refractory disease):

Per the 2025 AGA guideline, these are reserved for patients with symptoms refractory to medical therapies:

Intervention	Notes
Gastric Per-Oral Endoscopic Pyloromyotomy (G-POEM)	Endoscopic division of pyloric muscle; shown to improve symptoms and gastric emptying; AGA conditionally recommends against routine initial use
Gastric Electrical Stimulation (GES / Enterra device)	FDA-approved for refractory nausea/vomiting; may help symptom control even without improving gastric emptying; AGA recommends against routine initial use
Botulinum toxin injection into pylorus	Benefit shown in open-label studies; controlled trials show no benefit vs. saline; predictors of response: idiopathic etiology, female, age <50, higher dose (200 units)
Surgical pyloroplasty / pyloromyotomy	2025 AGA identified knowledge gaps; no formal recommendation
Gastrostomy tube for decompression	G-tube in severe refractory disease

Yamada's Textbook of Gastroenterology, 7th ed., pp. 670-671
Fischer's Mastery of Surgery, 8th ed., pp. 2886-2889
Sleisenger & Fordtran's GI and Liver Disease, pp. 863-866

Key 2025 AGA Guideline Takeaways (PMID: 40976635)

Published in Gastroenterology (October 2025), the American Gastroenterological Association issued 12 recommendations:

Use 4-hour GES, not 2-hour, for diagnosis
Metoclopramide and erythromycin are the recommended first-line pharmacologic agents
Against routine use of: domperidone, prucalopride, aprepitant, nortriptyline, buspirone, cannabidiol as first-line
G-POEM and GES should be reserved for patients failing medical therapy
Considerable unmet needs remain in gastroparesis treatment

Summary Algorithm

Suspected gastroparesis
        ↓
Rule out obstruction → Upper endoscopy (EGD)
        ↓
Lab workup → CBC, CMP, HbA1c, TSH, nutritional markers
        ↓
Stop offending meds → opioids, GLP-1 agonists
        ↓
Optimize glycemic control (if diabetic)
        ↓
4-hour Gastric Emptying Scintigraphy
        ↓
Confirmed delayed emptying (>10% at 4h)
        ↓
MILD (10-15%)          MODERATE (15-35%)        SEVERE (>35%)
Diet + metoclopramide  + Antiemetics + nutrition  + Domperidone/erythromycin
prn                    support (liquids/PEJ)      + Symptom modulators
                                                  + Consider G-POEM/GES

Can you generate an image for this?

Generating Image

A clean medical clinical reference infographic titled "Gastroparesis: Clinical Overview" with four organized sections arranged in a grid layout. Section 1 labeled "Symptoms" lists: nausea (most common), vomiting of undigested food 3-4h post-meal, early satiety, postprandial bloating, abdominal pain, weight loss, succussion splash on exam. Section 2 labeled "Causes" lists with percentages: Idiopathic 40%, Diabetic 35%, Postsurgical 20%, Other 5%, with a note about ICC depletion and pylorospasm as mechanisms. Section 3 labeled "Workup" shows a step-by-step flow: Step 1 Upper endoscopy to rule out obstruction, Step 2 Labs (CBC, CMP, HbA1c, TSH, nutritional markers), Step 3 Stop offending meds (opioids, GLP-1 agonists), Step 4 4-hour Gastric Emptying Scintigraphy - gold standard, with severity thresholds: Mild 10-15%, Moderate 15-35%, Severe over 35% retention at 4 hours. Section 4 labeled "Management" shows three columns by severity - Mild: diet modification plus metoclopramide PRN; Moderate: add antiemetics plus nutritional support; Severe: erythromycin, ondansetron, jejunostomy tube, consider G-POEM or gastric electrical stimulation. A footer note reads "2025 AGA Guideline: 4-hour scintigraphy required; metoclopramide and erythromycin are first-line pharmacotherapy." Professional medical illustration style with a muted blue and white color scheme, clear typography, and subtle anatomical stomach icon in the header.

Gastroparesis Clinical Overview Infographic

Here's the clinical summary infographic covering all four key areas:

Symptoms - cardinal features including the pathognomonic vomiting of undigested food
Causes - etiology breakdown by prevalence with pathophysiology note
Workup - stepwise diagnostic approach with the 4-hour scintigraphy thresholds
Management - severity-stratified treatment ladder from dietary changes through procedural interventions

The footer highlights the core 2025 AGA guideline update on 4-hour testing and first-line pharmacotherapy.

Now, use this image as well and create a PowerPoint presentation for me of this topic. Try to make 10 slides.

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Running Command

node /home/daytona/skills/shared/scripts/fetch_images.js "https://cdn.orris.care/image-gen/e01a8dbd560a47b49f8f43366126688f.png" 2>/dev/null | head -c 200

Running Command

mkdir -p /home/daytona/workspace/gastroparesis-pptx && ls /home/daytona/workspace/gastroparesis-pptx/

Writing File

~/gastroparesis-pptx/build.js

const pptxgen = require("pptxgenjs");
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);
const infographicB64 = imgResult[0].base64;

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  s.addText(dmPoints.map((t, i) => ({ text: t, options: { bullet: true, breakLine: i < dmPoints.length - 1 } })), {
    x: 5.4, y: 4.02, w: 4.15, h: 0.97,
    fontSize: 10, color: C.lightGray, fontFace: FONT, margin: 0,
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 5 — Diagnostic Workup
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  lightBg(s);
  headerBar(s, "Diagnostic Workup", "Step-by-step evaluation algorithm");
  footer(s, 5);

  const steps = [
    {
      num: "1",
      title: "Upper Endoscopy (EGD)",
      body: "First step — exclude mechanical obstruction: peptic stricture, pyloric stenosis, neoplasm, bezoar. Note: high aspiration risk in this population.",
      color: C.teal,
    },
    {
      num: "2",
      title: "Laboratory Studies",
      body: "CBC · CMP · HbA1c · TSH · Prealbumin/Transferrin · Electrolytes (K⁺, Ca²⁺). Exclude: DKA, uremia, hypocalcemia, hypothyroidism.",
      color: C.teal,
    },
    {
      num: "3",
      title: "Medication Review",
      body: "Discontinue motility-inhibiting drugs: opioids, GLP-1 agonists (semaglutide), anticholinergics, Ca²⁺ channel blockers.",
      color: C.gold,
    },
    {
      num: "4",
      title: "4-Hour Gastric Emptying Scintigraphy",
      body: "Gold standard. Tc-99m labeled 240 kcal low-fat egg meal. Scans at 0, 1, 2, 4 hours. Diagnostic: >10% retention at 4 h.\n2025 AGA: AGAINST 2-hour testing; FOR 4-hour testing.",
      color: C.red,
    },
  ];

  steps.forEach((step, i) => {
    const x = i < 2 ? 0.3 : 0.3;
    const col = i < 2 ? 0 : 1;
    const row = i % 2;
    const sx = col === 0 ? (i === 0 ? 0.3 : 5.15) : 0;
    // layout: 2 per row
    const lx = i % 2 === 0 ? 0.3 : 5.15;
    const ly = 1.3 + Math.floor(i / 2) * 2.1;
    card(s, lx, ly, 4.55, 1.9, C.white);
    // color accent top
    s.addShape(pres.ShapeType.rect, {
      x: lx, y: ly, w: 4.55, h: 0.08,
      fill: { color: step.color }, line: { color: step.color },
    });
    // number badge
    s.addShape(pres.ShapeType.rect, {
      x: lx + 0.15, y: ly + 0.15, w: 0.42, h: 0.42,
      fill: { color: step.color }, line: { color: step.color },
    });
    s.addText(step.num, {
      x: lx + 0.15, y: ly + 0.15, w: 0.42, h: 0.42,
      fontSize: 16, bold: true, color: C.white, fontFace: FONT,
      align: "center", valign: "middle", margin: 0,
    });
    s.addText(step.title, {
      x: lx + 0.68, y: ly + 0.18, w: 3.72, h: 0.38,
      fontSize: 12, bold: true, color: C.teal, fontFace: FONT, margin: 0,
    });
    s.addText(step.body, {
      x: lx + 0.2, y: ly + 0.62, w: 4.22, h: 1.2,
      fontSize: 9.5, color: C.darkText, fontFace: FONT, margin: 0,
    });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 6 — Severity Classification
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  lightBg(s);
  headerBar(s, "Severity Classification", "Gastric emptying scintigraphy — 4-hour retention thresholds");
  footer(s, 6);

  const severities = [
    {
      label: "MILD",
      range: "10 – 15%",
      retention: "Retention at 4 h",
      color: "2EAA6A",
      points: [
        "Symptoms manageable",
        "Dietary modification sufficient",
        "Metoclopramide PRN",
        "Nutritional support rarely needed",
        "No procedural intervention",
      ],
    },
    {
      label: "MODERATE",
      range: "15 – 35%",
      retention: "Retention at 4 h",
      color: C.gold,
      points: [
        "More frequent symptoms",
        "Regular dietary modification",
        "Scheduled prokinetics + antiemetics",
        "Caloric liquid supplements",
        "PEJ tube occasionally needed",
      ],
    },
    {
      label: "SEVERE",
      range: "> 35%",
      retention: "Retention at 4 h",
      color: C.red,
      points: [
        "Debilitating symptoms",
        "Blenderized diet routinely",
        "Multiple pharmacologic agents",
        "PEJ tube / parenteral nutrition",
        "Consider G-POEM or GES",
      ],
    },
  ];

  severities.forEach((sev, i) => {
    const sx = 0.3 + i * 3.2;
    // top color header
    s.addShape(pres.ShapeType.rect, {
      x: sx, y: 1.28, w: 2.95, h: 0.82,
      fill: { color: sev.color }, line: { color: sev.color },
    });
    s.addText(sev.label, {
      x: sx, y: 1.3, w: 2.95, h: 0.42,
      fontSize: 18, bold: true, color: C.white, fontFace: FONT,
      align: "center", margin: 0, charSpacing: 3,
    });
    s.addText(sev.range, {
      x: sx, y: 1.7, w: 2.95, h: 0.34,
      fontSize: 13, bold: true, color: C.white, fontFace: FONT,
      align: "center", margin: 0,
    });
    card(s, sx, 2.1, 2.95, 2.8, C.white);
    s.addText(sev.retention, {
      x: sx + 0.1, y: 2.15, w: 2.75, h: 0.32,
      fontSize: 9, italic: true, color: "888888", fontFace: FONT,
      align: "center", margin: 0,
    });
    s.addText(sev.points.map((t, idx) => ({ text: t, options: { bullet: true, breakLine: idx < sev.points.length - 1 } })), {
      x: sx + 0.12, y: 2.52, w: 2.73, h: 2.3,
      fontSize: 10, color: C.darkText, fontFace: FONT, margin: 0,
    });
  });

  // footnote
  s.addText("Diagnostic threshold: Gastric retention >10% at 4 hours on standard scintigraphy (Tc-99m labeled 240 kcal low-fat egg meal)", {
    x: 0.3, y: 5.1, w: 9.4, h: 0.22,
    fontSize: 8.5, color: "888888", fontFace: FONT, italic: true, margin: 0,
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 7 — General & Dietary Management
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  lightBg(s);
  headerBar(s, "General & Dietary Management", "First-line measures for all patients");
  footer(s, 7);

  // General measures
  card(s, 0.3, 1.3, 9.4, 1.22, C.white);
  accentBar(s, 0.3, 1.3, 1.22, C.teal);
  s.addText("General Measures (ALL Patients)", {
    x: 0.55, y: 1.38, w: 9.0, h: 0.36,
    fontSize: 13, bold: true, color: C.teal, fontFace: FONT, margin: 0,
  });
  s.addText("Stop offending medications (opioids, GLP-1 agonists, anticholinergics)   |   Optimize glycemic control in diabetics   |   Treat underlying cause", {
    x: 0.55, y: 1.76, w: 9.0, h: 0.66,
    fontSize: 11, color: C.darkText, fontFace: FONT, margin: 0,
  });

  // Dietary table
  const dietRows = [
    ["Dietary Principle", "Mild", "Moderate", "Severe"],
    ["Meal frequency", "Small, frequent (4–6/day)", "Small, frequent (4–6/day)", "Small, frequent (4–6/day)"],
    ["Fat content", "Low fat", "Low fat", "Low fat"],
    ["Fiber", "Low fiber", "Low fiber", "Low fiber"],
    ["Texture", "Normal; blenderized PRN", "Blenderized (small particle)", "Blenderized routinely"],
    ["Liquids", "Normal", "Caloric liquid supplements", "Liquid diet as primary intake"],
    ["Enteral support", "Rarely needed", "PEJ tube (occasionally)", "PEJ tube / TPN if severe malnutrition"],
  ];
  const colW = [2.6, 2.2, 2.2, 2.2];
  const tableX = 0.3;
  const tableY = 2.65;
  const rowH = 0.38;
  dietRows.forEach((row, ri) => {
    let cx = tableX;
    row.forEach((cell, ci) => {
      const isHeader = ri === 0;
      s.addShape(pres.ShapeType.rect, {
        x: cx, y: tableY + ri * rowH, w: colW[ci], h: rowH,
        fill: { color: isHeader ? C.teal : (ri % 2 === 0 ? C.offWhite : C.white) },
        line: { color: C.lightGray, width: 0.5 },
      });
      s.addText(cell, {
        x: cx + 0.06, y: tableY + ri * rowH + 0.04, w: colW[ci] - 0.12, h: rowH - 0.08,
        fontSize: isHeader ? 10 : 9,
        bold: isHeader,
        color: isHeader ? C.white : C.darkText,
        fontFace: FONT, margin: 0, valign: "middle",
      });
      cx += colW[ci];
    });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 8 — Pharmacological Treatment
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  lightBg(s);
  headerBar(s, "Pharmacological Treatment", "Prokinetics · Antiemetics · Neuromodulators");
  footer(s, 8);

  // AGA 2025 banner
  s.addShape(pres.ShapeType.rect, {
    x: 0.3, y: 1.3, w: 9.4, h: 0.42,
    fill: { color: C.navy }, line: { color: C.navy },
  });
  s.addText("2025 AGA Guideline  —  First-line: Metoclopramide OR Erythromycin  |  Against: Domperidone, Prucalopride, Aprepitant, Nortriptyline, Buspirone, Cannabidiol as first-line", {
    x: 0.38, y: 1.33, w: 9.25, h: 0.36,
    fontSize: 9.5, color: C.gold, fontFace: FONT, bold: true, margin: 0,
  });

  // Prokinetics
  card(s, 0.3, 1.85, 4.55, 1.78, C.white);
  accentBar(s, 0.3, 1.85, 1.78, C.teal);
  s.addText("Prokinetics", {
    x: 0.55, y: 1.93, w: 4.2, h: 0.36,
    fontSize: 13, bold: true, color: C.teal, fontFace: FONT, margin: 0,
  });
  const prokinetics = [
    "Metoclopramide 5–10 mg PO before meals (D2 antagonist) ✓ First-line — risk of tardive dyskinesia; limit to 12 wks",
    "Erythromycin 125 mg PO bid (motilin agonist) ✓ First-line — tachyphylaxis with prolonged use",
    "Domperidone 10–20 mg PO tid (⚠ 2025 AGA: against as first-line)",
    "Prucalopride 2 mg daily — 5HT4 agonist (⚠ 2025 AGA: against as first-line)",
  ];
  s.addText(prokinetics.map((t, i) => ({ text: t, options: { bullet: true, breakLine: i < prokinetics.length - 1 } })), {
    x: 0.55, y: 2.32, w: 4.2, h: 1.24,
    fontSize: 9.5, color: C.darkText, fontFace: FONT, margin: 0,
  });

  // Antiemetics
  card(s, 5.15, 1.85, 4.5, 1.78, C.white);
  accentBar(s, 5.15, 1.85, 1.78, C.gold);
  s.addText("Antiemetics", {
    x: 5.4, y: 1.93, w: 4.15, h: 0.36,
    fontSize: 13, bold: true, color: C.teal, fontFace: FONT, margin: 0,
  });
  const antiemetics = [
    "Ondansetron 4–8 mg TID PO/SL/IV (5-HT3 antagonist)",
    "Promethazine 12.5–25 mg q4–6h PO/PR/IM",
    "Prochlorperazine 5–10 mg PO/IM",
    "Aprepitant 40–80 mg (NK1 antagonist — severe/refractory)",
    "Mirtazapine 15–30 mg daily (severe, poor appetite)",
  ];
  s.addText(antiemetics.map((t, i) => ({ text: t, options: { bullet: true, breakLine: i < antiemetics.length - 1 } })), {
    x: 5.4, y: 2.32, w: 4.15, h: 1.24,
    fontSize: 9.5, color: C.darkText, fontFace: FONT, margin: 0,
  });

  // Neuromodulators
  card(s, 0.3, 3.77, 9.4, 1.23, C.white);
  accentBar(s, 0.3, 3.77, 1.23, C.red);
  s.addText("Symptom Modulators / Neuromodulators  (Severe / Refractory)", {
    x: 0.55, y: 3.85, w: 9.0, h: 0.36,
    fontSize: 12, bold: true, color: C.teal, fontFace: FONT, margin: 0,
  });
  s.addText(
    "Nortriptyline 10–25 mg (TCA — benefit for anorexia/weight; no overall benefit in idiopathic GP per RCT)   |   Buspirone (⚠ 2025 AGA: against first-line)   |   Acupuncture (moderate disease)",
    {
      x: 0.55, y: 4.23, w: 9.0, h: 0.7,
      fontSize: 10, color: C.darkText, fontFace: FONT, margin: 0,
    }
  );
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 9 — Procedural & Surgical Options
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  lightBg(s);
  headerBar(s, "Procedural & Surgical Options", "Reserved for medically refractory gastroparesis");
  footer(s, 9);

  // caveat banner
  s.addShape(pres.ShapeType.rect, {
    x: 0.3, y: 1.3, w: 9.4, h: 0.38,
    fill: { color: C.red }, line: { color: C.red },
  });
  s.addText("2025 AGA: G-POEM and Gastric Electrical Stimulation should be reserved for patients FAILING medical therapy — not for routine initial use", {
    x: 0.38, y: 1.32, w: 9.25, h: 0.34,
    fontSize: 9.5, color: C.white, fontFace: FONT, bold: true, margin: 0,
  });

  const procedures = [
    {
      name: "G-POEM",
      full: "Gastric Per-Oral Endoscopic Pyloromyotomy",
      body: "Endoscopic division of pyloric muscle via submucosal tunnel. Improves gastric emptying and symptoms. Predictors of response: idiopathic etiology, female sex, age <50.",
      color: C.teal,
    },
    {
      name: "GES",
      full: "Gastric Electrical Stimulation (Enterra™)",
      body: "FDA-approved for refractory nausea/vomiting. Implantable device delivers high-frequency, low-energy pulses. May improve symptoms without improving emptying (mechanism unclear).",
      color: C.navy,
    },
    {
      name: "Botox",
      full: "Pyloric Botulinum Toxin Injection",
      body: "Reduces pylorospasm. Open-label studies positive; two small RCTs showed NO benefit vs. saline. Best response: idiopathic GP, female, age <50, dose 200 units.",
      color: C.gold,
    },
    {
      name: "Surgery",
      full: "Pyloroplasty / Pyloromyotomy / Gastrostomy",
      body: "Surgical pyloroplasty/myotomy: limited RCT data; 2025 AGA identified knowledge gaps. G-tube: decompression in severe refractory disease. PEJ tube for nutritional support.",
      color: C.red,
    },
  ];

  procedures.forEach((proc, i) => {
    const px = i % 2 === 0 ? 0.3 : 5.15;
    const py = 1.85 + Math.floor(i / 2) * 1.78;
    card(s, px, py, 4.55, 1.62, C.white);
    s.addShape(pres.ShapeType.rect, {
      x: px, y: py, w: 0.85, h: 1.62,
      fill: { color: proc.color }, line: { color: proc.color },
    });
    s.addText(proc.name, {
      x: px + 0.02, y: py + 0.55, w: 0.81, h: 0.52,
      fontSize: 13, bold: true, color: C.white, fontFace: FONT,
      align: "center", margin: 0,
    });
    s.addText(proc.full, {
      x: px + 0.98, y: py + 0.08, w: 3.45, h: 0.38,
      fontSize: 10.5, bold: true, color: C.teal, fontFace: FONT, margin: 0,
    });
    s.addText(proc.body, {
      x: px + 0.98, y: py + 0.48, w: 3.45, h: 1.07,
      fontSize: 9.5, color: C.darkText, fontFace: FONT, margin: 0,
    });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 10 — Summary Infographic & Key Takeaways
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  darkBg(s);

  // top band
  s.addShape(pres.ShapeType.rect, {
    x: 0, y: 0, w: "100%", h: 0.18,
    fill: { color: C.sky }, line: { color: C.sky },
  });
  s.addShape(pres.ShapeType.rect, {
    x: 0, y: 0.18, w: "100%", h: 0.06,
    fill: { color: C.gold }, line: { color: C.gold },
  });

  s.addText("Clinical Summary & Key Takeaways", {
    x: 0.4, y: 0.3, w: 9.2, h: 0.52,
    fontSize: 22, bold: true, color: C.white, fontFace: FONT,
    charSpacing: 1, margin: 0,
  });

  // infographic image (left)
  s.addImage({
    data: infographicB64,
    x: 0.25, y: 0.95, w: 5.3, h: 3.55,
  });

  // Key takeaways (right)
  const takeaways = [
    { icon: "▶", text: "4-hour scintigraphy is mandatory for diagnosis (2025 AGA)" },
    { icon: "▶", text: "Metoclopramide & erythromycin are the only first-line drugs" },
    { icon: "▶", text: "Vomiting undigested food >6 h post-meal is pathognomonic" },
    { icon: "▶", text: "Stop GLP-1 agonists and opioids before testing" },
    { icon: "▶", text: "Optimize glycemic control in ALL diabetic patients" },
    { icon: "▶", text: "G-POEM & GES: for refractory cases only, not routine" },
    { icon: "▶", text: "Multidisciplinary approach required for severe disease" },
  ];

  let ky = 1.02;
  takeaways.forEach(t => {
    s.addShape(pres.ShapeType.rect, {
      x: 5.75, y: ky, w: 3.95, h: 0.46,
      fill: { color: "15375F" }, line: { color: C.teal, width: 0.5 },
    });
    s.addText([
      { text: t.icon + "  ", options: { color: C.sky, bold: true } },
      { text: t.text, options: { color: C.white } },
    ], {
      x: 5.85, y: ky + 0.04, w: 3.78, h: 0.38,
      fontSize: 9.5, fontFace: FONT, margin: 0, valign: "middle",
    });
    ky += 0.52;
  });

  // bottom reference bar
  s.addShape(pres.ShapeType.rect, {
    x: 0, y: 5.25, w: "100%", h: 0.375,
    fill: { color: C.teal }, line: { color: C.teal },
  });
  s.addText("Fischer's Mastery of Surgery 8e  ·  Yamada's Textbook of Gastroenterology 7e  ·  Sleisenger & Fordtran's GI & Liver Disease  ·  2025 AGA Clinical Practice Guideline (PMID: 40976635)", {
    x: 0.3, y: 5.28, w: 9.4, h: 0.32,
    fontSize: 8, color: C.white, fontFace: FONT, align: "center", margin: 0,
  });
}

// ── Write file ────────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/gastroparesis-pptx/Gastroparesis_Clinical_Overview.pptx" })
  .then(() => console.log("SUCCESS: file written"))
  .catch(e => { console.error("ERROR:", e); process.exit(1); });

Running Command

cd /home/daytona/workspace/gastroparesis-pptx && node build.js 2>&1

Running Command

node /home/daytona/skills/shared/scripts/fetch_images.js "https://cdn.orris.care/image-gen/e01a8dbd560a47b49f8f43366126688f.png" > /home/daytona/workspace/gastroparesis-pptx/infographic_b64.json 2>&1; echo "exit: $?"

Editing File

~/gastroparesis-pptx/build.js

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/gastroparesis-pptx/build.js'

Editing File

~/gastroparesis-pptx/build.js

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/gastroparesis-pptx/build.js'

Running Command

cd /home/daytona/workspace/gastroparesis-pptx && node build.js 2>&1

Running Command

ls -lh /home/daytona/workspace/gastroparesis-pptx/Gastroparesis_Clinical_Overview.pptx

Your presentation is ready (1.5 MB, 10 slides):

Gastroparesis Clinical Overview

Presentation · PPTX

Here's a breakdown of the 10 slides:

#	Slide	Design
1	Title	Dark navy with teal/gold accent bands
2	Definition & Epidemiology	Stat cards (navy) + key points
3	Etiology & Pathophysiology	Color-coded cause blocks (40/35/20/5%) + mechanism bullets
4	Clinical Presentation	Cardinal symptoms + exam findings + diabetic-specific callout box
5	Diagnostic Workup	4-step numbered card layout
6	Severity Classification	Three-column mild/moderate/severe table with color-coded headers
7	General & Dietary Management	Full dietary management table by severity
8	Pharmacological Treatment	2025 AGA banner + prokinetics / antiemetics / neuromodulators cards
9	Procedural & Surgical Options	G-POEM, GES, Botox, Surgery - each with color-coded panel
10	Summary & Key Takeaways	Your infographic embedded + 7 key takeaway bullets on dark background

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