GLP‐1 Receptor Agonists and Endoscopy: Understanding Gastric Stasis, Aspiration Risk, and Contemporary Peri‐Procedural Guidance

Abstract

The global increase in obesity, type 2 diabetes mellitus (T2DM), and metabolic dysfunction‐associated steatotic liver disease (MASLD) has led to a higher use of glucagon‐like peptide‐1 receptor agonists (GLP‐1RAs) among patients undergoing gastrointestinal endoscopy. Although GLP‐1RAs provide significant metabolic, cardiovascular, and hepatic benefits, their tendency to slow gastric emptying has raised concerns about retained gastric contents (RGC), procedural complications, and a greater risk of pulmonary aspiration during sedation or anesthesia. This review offers a translational narrative synthesis of mechanistic, physiological, and clinical evidence connecting GLP‐1RA therapy to changes in gastric motility and peri‐endoscopic outcomes. Data from pharmacological studies, scintigraphic evaluations, large observational cohorts, and international consensus statements are combined to guide physiology‐based procedural decisions. Evidence consistently indicates that GLP‐1RA exposure is associated with a higher incidence of RGC and more frequent procedural disruptions during upper gastrointestinal endoscopy. However, it remains uncertain whether RGC leads to clinically significant aspiration. Consistent with this, real‐world data reveal no increase in aspiration pneumonia among GLP‐1RA users undergoing colonoscopy, with reported aspiration rates of approximately 0.01%–0.05%. Likewise, during upper gastrointestinal endoscopy, only a small absolute rise in aspiration‐related events has been observed, involving fewer than 0.3% of procedures. Current guidelines favor continuing GLP‐1RA therapy alongside dietary modification, structured risk assessment, selective gastric point‐of‐care ultrasound (POCUS), and multidisciplinary communication, rather than routine cessation. Emerging prospective evidence indicates that implementing a pre‐procedural clear liquid diet, with individualized timing of weekly agents, may reduce the risk of clinically significant RGC, complementing existing dietary preparation strategies.