Revista Científica Multidisciplinaria Arbitrada YACHASUN. Volumen 10, Número 18 (Ed. ene – jun. 2026) ISSN: 2697-3456

Gastric Ultrasound for Aspiration-Risk Stratification in Patients Receiving GLP-1 Receptor Agonists: An Integrated Systematic

Review and Evidence Update of Ultrasonographic, Endoscopic, and Anesthetic Outcomes.

DOI: https://doi.org/10.46296/yc.v10i18.0915

ULTRASONIDO GÁSTRICO PARA LA ESTRATIFICACIÓN DEL RIESGO DE

ASPIRACIÓN EN PACIENTES TRATADOS CON AGONISTAS GLP-1:

REVISIÓN SISTEMÁTICA INTEGRADA Y ACTUALIZACIÓN DE EVIDENCIA

SOBRE HALLAZGOS ULTRASONOGRÁFICOS, ENDOSCÓPICOS Y

DESENLACES ANESTÉSICOS

GASTRIC ULTRASOUND FOR ASPIRATION-RISK STRATIFICATION IN

PATIENTS RECEIVING GLP-1 RECEPTOR AGONISTS: AN INTEGRATED

SYSTEMATIC REVIEW AND EVIDENCE UPDATE OF

ULTRASONOGRAPHIC, ENDOSCOPIC, AND ANESTHETIC OUTCOMES

1

2

Naranjo-Ramos Ángel Augusto ; Ochoa-Montoya Blanca Cruzcaya ; Cevallos-Naranjo

3

4

5

Alejandra Sofia ; Pazmiño-Vera Katherine Liliana ; Alvarez-Pasaca Richard Paúl

1

Médico General, Hospital Manuel Ygnacio Monteros. Loja, Ecuador.

Correo: monillobarce@gmail.com. ORCID ID: https://orcid.org/0000-0001-8403-9903

2

Médico especialista en Radiología e Imagen, Hospital Manuel Ygnacio Monteros. Ecuador.

Correo: blancaochoa102@yahoo.es

3

Médico General, Ministerio de Salud Pública. Ecuador.

Correo: alesocena1@gmail.com. ORCID ID: https://orcid.org/0009-0007-5931-5751

4

Médico general, Hospital General Monte Sinaí. Guayaquil, Ecuador.

Correo: katherineliliana_1999@outlook.es. ORCID ID: https://orcid.org/0009-0008-2497-886X

5

Médico General, Centro Médico Biocem. Ecuador.

Correo: alva_rp_91@hotmail.com. ORCID ID: https://orcid.org/0009-0005-6594-9932

Resumen

Introducción: Los agonistas del receptor GLP-1 y los agonistas duales GLP-1/GIP retrasan el

vaciamiento gástrico. Los estudios endoscópicos muestran de manera consistente mayor

contenido gástrico residual (CGR), pero la aspiración pulmonar es infrecuente y el papel del

ultrasonido gástrico como herramienta individualizada de estratificación no se ha integrado

adecuadamente con los hallazgos endoscópicos y anestésicos. Métodos: Se realizó una revisión

sistemática integrada y actualización estructurada de evidencia. La evidencia endoscópica se

ancló a una revisión sistemática con búsqueda hasta el 7 de julio de 2025 (24 estudios

comparativos). Se efectuó una actualización dirigida en PubMed y rastreo de citas hasta el 27 de

agosto de 2026 para incorporar estudios de ultrasonido gástrico y nueva evidencia

endoscópica/anestésica. Se realizó un metaanálisis exploratorio de efectos aleatorios con cuatro

cohortes ecográficas controladas y definiciones compatibles de CGR elevado/estómago lleno.

Resultados: Se integraron 35 estudios primarios. En la síntesis endoscópica previa (184.707

participantes), los agonistas GLP-1 se asociaron con mayor CGR (OR 4,82; IC95% 3,66-6,35) y

mayor interrupción del procedimiento (OR 3,93; IC95% 2,42-6,39), sin aumento estadísticamente

significativo de aspiración (OR 1,10; IC95% 0,84-1,48). En cuatro cohortes ecográficas

controladas (n=461), la exposición a GLP-1 se asoció con CGR elevado/estómago lleno (OR

combinado 9,31; IC95% 3,68-23,57; I²=60,0%). El ensayo aleatorizado OCULUS de 2026 (n=60)

encontró volumen gástrico residual clínicamente significativo en 25,0% al continuar el tratamiento

frente a 3,1% al omitir una dosis. No se identificó un estudio de exactitud diagnóstica que

comparara, en los mismos pacientes tratados con GLP-1, ultrasonido gástrico preprocedimiento

con hallazgos posteriores de EGD. Conclusiones: La terapia basada en GLP-1 se asocia

fuertemente con CGR detectado por ultrasonido y endoscopia; la evidencia sobre aspiración

clínica sigue siendo inconsistente por la baja frecuencia del evento. El ultrasonido gástrico es

Información del manuscrito:

Fecha de recepción: 10 de marzo de 2026.

Fecha de aceptación: 20 de mayo de 2026.

Fecha de publicación: 22 de junio de 2026.

2

171

Naranjo-Ramos et al. (2026)

una herramienta prometedora para estratificación individualizada, pero requiere validación

pareada frente a endoscopia y estudios de impacto clínico.

Palabras claves: agonistas GLP-1; semaglutida; ultrasonido gástrico; POCUS; contenido gástrico

residual; endoscopia digestiva alta; aspiración; anestesia; sedación.

Abstract

Background: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and dual GLP-1/GIP

agonists delay gastric emptying. Observational endoscopy data consistently show more retained

gastric content (RGC), but pulmonary aspiration remains rare and the role of gastric ultrasound

as an individualized preprocedural triage tool has not been integrateld with endoscopic and

anesthetic outcomes. Methods: We performed an integrated systematic review and structured

evidence update. The endoscopy evidence base was anchored to a systematic review that

searched MEDLINE and the Cochrane Library through 7 July 2025 and included 24 comparative

studies. A targeted PubMed/citation update through 27 August 2026 expanded eligibility to

gastric-ultrasound studies and newly published endoscopy/anesthesia studies. Adults receiving

GLP-1 RA or GLP-1/GIP therapy were eligible when objective gastric content was assessed by

ultrasound or upper endoscopy, or when aspiration/anesthetic outcomes were reported. A

random-effects exploratory meta-analysis pooled four controlled gastric-ultrasound cohorts with

compatible definitions of increased RGC/full stomach. Results: The integrated evidence set

comprised 35 primary studies (24 carried forward and 11 newly integrated). The predecessor

endoscopy synthesis (184,707 participants) found higher RGC (OR 4.82, 95% CI 3.66-6.35) and

procedure discontinuation (OR 3.93, 95% CI 2.42-6.39), without a statistically significant increase

in aspiration (OR 1.10, 95% CI 0.84-1.48). In four controlled ultrasound cohorts (n=461), GLP-1

RA exposure was associated with increased RGC/full stomach (pooled crude OR 9.31, 95% CI

3.68-23.57; I²=60.0%). The 2026 OCULUS randomized trial (n=60) found clinically significant

residual gastric volume in 25.0% of patients continuing therapy versus 3.1% withholding one

dose. No eligible same-patient diagnostic-accuracy study directly validated gastric ultrasound

against subsequent EGD findings in GLP-1-treated patients. Conclusions: GLP-1-based therapy

is strongly associated with RGC detected by both ultrasound and endoscopy, whereas evidence

for increased aspiration is inconsistent and limited by rare events. Gastric ultrasound is a

promising individualized risk-stratification adjunct, but its diagnostic agreement with endoscopic

findings and its ability to reduce clinically important aspiration events require prospective paired

validation.

Keywords: GLP-1 receptor agonist; semaglutide; gastric ultrasound; POCUS; retained gastric

content; upper gastrointestinal endoscopy; aspiration; anesthesia; sedation.

surrogate marker of risk—retained

1

. Introduction

gastric

increased, while the clinically

decisive event—pulmonary

content—is

consistently

GLP-1 receptor agonists are now

widely prescribed for type 2 diabetes

and obesity, and dual GLP-1/GIP

aspiration—remains uncommon and

agonists

are

increasingly

difficult to study. Recent endoscopy

encountered in patients presenting

for procedural sedation or general

anesthesia. Their pharmacologic

effect on gastric motility has created

a clinically important tension: the

meta-analyses

have

therefore

converged on a strong association

with RGC and procedure interruption

but have produced discordant

estimates for aspiration [1-3].

2

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Revista Científica Multidisciplinaria Arbitrada YACHASUN. Volumen 10, Número 18 (Ed. ene – jun. 2026) ISSN: 2697-3456

Gastric Ultrasound for Aspiration-Risk Stratification in Patients Receiving GLP-1 Receptor Agonists: An Integrated Systematic

Review and Evidence Update of Ultrasonographic, Endoscopic, and Anesthetic Outcomes.

The practical challenge is particularly

relevant to upper gastrointestinal

endoscopy. Deep sedation can

diminish protective airway reflexes,

ultrasound-guided

changes

in

anesthetic management reduce

aspiration events.

The objective of this review was

therefore to integrate three clinically

connected evidence domains—

gastric ultrasound, upper endoscopy,

while

endoscopic

visualization

provides direct confirmation of

gastric contents only after sedation

has begun. Gastric point-of-care

ultrasound (POCUS), in contrast, can

be performed before induction and

can identify solid content or estimate

clear-fluid volume. Contemporary

multidisciplinary recommendations

increasingly include a 24-hour clear-

fluid strategy and gastric ultrasound

when residual-content risk remains

uncertain [4,5].

and

anesthetic

outcomes—in

patients receiving GLP-1-based

therapy. We specifically aimed to: (1)

quantify the association between

GLP-1 exposure and

a

full

stomach/increased RGC on gastric

ultrasound; (2) contextualize these

findings against the established

endoscopic evidence base; (3)

summarize aspiration and airway-

management outcomes; and (4)

identify whether direct same-patient

ultrasound-to-endoscopy validation

exists.

However, the evidence supporting

gastric ultrasound and the evidence

derived from endoscopic cohorts

have largely evolved in parallel.

Ultrasound studies typically involve

perioperative surgical populations

rather than patients proceeding

directly to EGD, whereas endoscopy

studies rely on intraprocedural visual

or suction-based definitions of RGC.

Consequently, it is not yet clear

whether a preprocedural ultrasound

finding in a GLP-1-treated patient

2

. Methods

Design

2

.1

and

reporting

framework

This manuscript is an integrated

systematic review and structured

evidence update, reported according

to PRISMA 2020 principles where

applicable [33]. It was designed as a

modality expansion of a recent

accurately

predicts

what

the

gastroenterologist will encounter

during subsequent EGD, or whether

2

173

Naranjo-Ramos et al. (2026)

systematic review of upper-GI

endoscopy outcomes rather than as

a de novo recreation of that review’s

database search. This distinction is

explicit in the flow diagram and is

important for reproducibility.

agent, an alternative glucose-

lowering drug, or an alternative

withholding strategy when available.

Outcomes: objectively assessed

RGC/full

stomach

by

gastric

ultrasound or EGD, procedure

interruption, aspiration/regurgitation,

urgent airway intervention/intubation,

or other clinically relevant anesthetic

outcomes.

The review was not prospectively

registered. The endoscopy evidence

base through 7 July 2025 was carried

forward from Malandris et al. [1],

whose

review

included

24

Comparative cohort, case-control,

cross-sectional, and randomized

comparative observational studies. A

targeted update and modality-

studies

Noncomparative

retained only

synthesis of rare adverse outcomes

or ultrasound-based risk

were

cohorts

for

eligible.

expansion

search

was

then

were

performed to identify gastric-

ultrasound studies and newer

descriptive

endoscopy/anesthesia

studies

through 27 August 2026.

stratification. Case reports, case

series without an analyzable cohort,

editorials, comments, guidelines,

narrative reviews, and systematic

reviews were excluded from the

primary evidence set, although high-

quality secondary sources were used

to contextualize the findings.

2

.2 Eligibility criteria

Population: adults (≥18 years)

receiving a GLP-1 receptor agonist

or dual GLP-1/GIP agonist and

undergoing upper gastrointestinal

endoscopy,

procedural

sedation/general anesthesia, or

preprocedural gastric ultrasound.

Exposure: current or recent GLP-1-

2

.3 Information sources and

search strategy

based

therapy,

including

The legacy endoscopy branch was

based on the MEDLINE/PubMed and

Cochrane Library search reported by

Malandris et al. through 7 July 2025

[1]. For the present modality

semaglutide, liraglutide, dulaglutide,

exenatide, lixisenatide, tirzepatide,

or class-level exposure. Comparator:

patients not receiving a GLP-1-based

2

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Gastric Ultrasound for Aspiration-Risk Stratification in Patients Receiving GLP-1 Receptor Agonists: An Integrated Systematic

Review and Evidence Update of Ultrasonographic, Endoscopic, and Anesthetic Outcomes.

expansion and update, PubMed-

indexed records and

EGD OR "upper endoscopy" OR

aspiration OR regurgitation).

backward/forward citation links were

searched through 27 August 2026. A

The update branch was intentionally

focused on evidence that could

materially change the imaging–

endoscopy–anesthesia

core

search

concept

was:

("glucagon-like peptide-1 receptor

agonist" OR GLP-1 OR GLP-1RA

OR semaglutide OR liraglutide OR

dulaglutide OR exenatide OR

lixisenatide OR tirzepatide) AND

interpretation. It is therefore best

described as a structured evidence

update rather than a new, fully

independent multi-database search.

The search log and evidence-

assembly counts are provided in

Supplementary Table S1 and Figure

("gastric

ultrasound"

OR

ultrasonography OR POCUS OR

"

residual gastric content" OR

retained gastric content" OR "gastric

1

.

residue"

OR

esophagogastroduodenoscopy OR

Supplementary Table S1. Update/modality-expansion search log

Stage

n

Explanation

Candidate reports identified 28

in targeted PubMed/citation

search

All candidate reports logged before evidence-set adjudication.

Known legacy/duplicate

reports

9

Already represented in the 24-study predecessor endoscopy review.

Records screened after

removal

19

6

Title/abstract relevance to ultrasound, new endoscopy, or anesthetic

outcomes.

Excluded at title/abstract

Systematic/meta-analyses, guideline/consensus documents, or

secondary reviews.

Full-text reports assessed

Full-text reports excluded

13

2

Original-research eligibility checked.

Comment/reply; not original research.

New primary studies

included

11

6 gastric-ultrasound studies + 5 newer endoscopy/anesthesia studies.

Total integrated primary

studies

35

24 legacy + 11 newly integrated.

gastric ultrasound. When available,

2

.4 Outcomes and definitions

this was defined as visible solid/thick

content or estimated clear-fluid

volume >1.5 mL/kg in the right lateral

The primary imaging outcome was

increased RGC or “full stomach” on

2

175

Naranjo-Ramos et al. (2026)

decubitus position. Endoscopic RGC

definitions varied and included visible

solid food, retained liquid, “poor

preparation,” or measured/aspirated

fluid above study-specific thresholds.

Because these constructs are related

but not identical, ultrasound and

endoscopy estimates were not

pooled together.

full stomach/increased RGC were

pooled in an exploratory random-

effects meta-analysis using crude

event counts (Sen et al. [10],

Nersessian et al. [19], Queiroz et al.

[22], and Vlaeminck et al. [28]).

DerSimonian-Laird between-study

variance was used; heterogeneity

was expressed with I². Sherwin et al.

[

9] was not pooled because it was a

Secondary

pulmonary

outcomes were

aspiration/aspiration

very small volunteer study focused

on solid-content prevalence by

position rather than the same

composite full-stomach threshold.

Pai et al. [27] lacked a non-exposed

comparator and was synthesized

descriptively.

pneumonia, regurgitation, procedure

discontinuation, urgent endotracheal

intubation or change in airway plan,

and the influence of withholding

interval, clear-liquid preparation, or

concurrent colonoscopy.

2

.6 Methodological quality

2

.5 Data synthesis

For the legacy endoscopy evidence,

we relied on the formal ROBINS-I v2

and GRADE assessments reported

by Malandris et al. [1]. Most studies

were judged at low risk for the

primary outcome, with four studies at

serious risk mainly because of

residual confounding and four

abstract-only studies at moderate

risk; the certainty of evidence was

rated very low. For the 11 newly

integrated reports, we performed a

The 24-study endoscopy meta-

analysis from the predecessor review

was treated as

a

validated

benchmark rather than recomputed,

because its study-level extraction,

overlap adjudication, and random-

effects modeling had already been

completed [1]. New post-update

endoscopy evidence was integrated

narratively.

Gastric-ultrasound

studies were synthesized separately.

structured

single-reviewer

Four controlled ultrasound cohorts

with compatible binary definitions of

methodological appraisal focused on

confounding, exposure classification,

2

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Gastric Ultrasound for Aspiration-Risk Stratification in Patients Receiving GLP-1 Receptor Agonists: An Integrated Systematic

Review and Evidence Update of Ultrasonographic, Endoscopic, and Anesthetic Outcomes.

outcome ascertainment, selection,

and reporting. Because a second

independent reviewer did not repeat

this update appraisal, these ratings

are presented as methodological

candidate reports were logged. Nine

represented known legacy/duplicate

reports, leaving 19 records for

screening.

Six

secondary

reviews/guidelines were excluded at

title/abstract level. Thirteen reports

were assessed in full text; two were

concerns

rather

than

formal

duplicate-review

judgments.

ROBINS-I

comments/replies

rather

than

original research, leaving 11 newly

integrated primary studies. The final

integrated evidence set therefore

comprised 35 primary studies (Figure

3

. Results

3

.1 Study selection and evidence

set

1

). Eight legacy studies were

The predecessor endoscopy review

screened 255 records, assessed 58

full-text reports, and included 24

observational studies [1]. In the

present update/modality branch, 28

available only as conference

abstracts; 27 full-text primary reports

are summarized in Table 1.

Figure 1. PRISMA-informed evidence assembly flow for the integrated systematic review and

structured update

2

177

Naranjo-Ramos et al. (2026)

Table 1. Characteristics and key findings of 27 full-text primary studies

Study

Design /

setting

Sample

Exposure

Outcome

Key finding

Stark 2022 [6]

Kobori 2023 [7]

Retrospective 177 (59 vs

matched EGD 118)

GLP-1 RA

class

Endoscopic

retained food

6.8% vs 1.7%; early signal, not

statistically definitive

Matched case- 410

GLP-1 RA

class; T2D

Gastric

residue on

EGD

5.4% vs 0.49%; P=0.004

control EGD

matched

205 pairs)

(

Silveira 2023 [8] Retrospective 404 (33 vs

Semaglutide Increased

RGC;

24.2% vs 5.1%; adjusted OR 5.15;

1 aspiration in exposed

EGD

371)

aspiration

Sherwin 2023 [9] Prospective

volunteer

20 (10 vs

10)

Semaglutide Residual

solids after

Supine solids 70% vs 10%; lateral

90% vs 20%

ultrasound

fasting

Sen 2024 [10]

Wu 2024 [11]

Nadeem 2024

Prospective

cross-sectional 62)

ultrasound

124 (62 vs

Weekly

GLP-1 RA

Increased

RGC on

ultrasound

56% vs 19%; adjusted prevalence

ratio 2.48

Historical

cohort EGD

192 (90 vs

102)

GLP-1 RA

class

Visible

contents;

airway events

18.9% vs 4.9%; adjusted OR 5.8;

urgent intubation 5 vs 1

Large

35,183 (922 GLP-1 RA

RGC;

~4-fold higher RGC and aborted

[

12]

retrospective

EGD

exposed)

class

aborted/repeat EGD; ~2-fold repeat EGD

EGD

Nasser 2024 [13] Cross-

141 (47 vs

GLP-1 RA

class

Food retention Solid retention 8.5% vs 0% in

reported comparison

sectional EGD 94)

Chapman 2024

14]

Case-control

EGD

168 (84

pairs)

GLP-1 RA

class

Visibility; RGC; RGC 13.1% vs 4.8%; adjusted OR

[

abortion

4.62; no anesthesia AEs

Abu-Freha 2024 Multicenter

120,879

(1,671

exposed)

GLP-1 RA

class

Gastric

residue

5.6% vs 2.0%; GLP-1 use

independent risk factor

[

15]

retrospective

EGD

Yeo 2024 [16]

Claims-based ~30,177

GLP-1 RA

class

Aspiration

pneumonia

Reported increased aspiration-

pneumonia signal; contrasts with

other large cohorts

cohort

matched

Alkabbani 2024

Comparative

cohort EGD

43,365

GLP-1 RA

vs SGLT2

inhibitor

Aspiration;

discontinuation discontinuation RR 1.99

Aspiration RR 0.98 (0.73-1.31);

[

17]

Santos 2024 [18] Retrospective 1,094 (123

Semaglutide RGC by

semaglutide) withholding

interval

20.3% vs 3.2%; symptoms and

shorter interruption associated with

RGC

EGD

Nersessian 2024 Prospective

220 (107 vs Semaglutide Increased

40% vs 3%; weighted OR 36.97;

no aspiration

[

19]

ultrasound

113)

RGC

Elimihele 2024

20]

Retrospective Full-text

EGD cohort

GLP-1 RA

class

RGC in

Confounding-sensitive association;

[

asymptomatic highlights comorbidity effects

patients

Anazco 2024

21]

Retrospective 4,000+ GLP- GLP-1 RA

Pulmonary

aspiration

Very low absolute aspiration

incidence

[

upper

1-treated

EGDs

class

endoscopy

cohort

Queiroz 2025

22]

Prospective

volunteer

30 (15 vs

15)

Semaglutide Full stomach

73% vs 7%; P<0.001

[

ultrasound

Firkins 2025 [23] Clinical

outcomes

EGD cohort

Full-text

cohort

GLP-1 RA

class

RGC/safety

outcomes

Supports low absolute severe-

event rate despite retention

concern

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Gastric Ultrasound for Aspiration-Risk Stratification in Patients Receiving GLP-1 Receptor Agonists: An Integrated Systematic

Review and Evidence Update of Ultrasonographic, Endoscopic, and Anesthetic Outcomes.

Study

Design /

setting

Sample

Exposure

Outcome

Key finding

Gu 2025 [24]

Dev 2025 [25]

Retrospective 304 (152 vs Semaglutide RGC

matched EGD 152)

12.5% vs 1.3%; several RGC

EGDs aborted

Large

retrospective

EGD

32,275

(1,179

GLP-1 RA

class

Aborted EGD

due to food

0.6% vs 0.096%; no aspiration

among retained-food cases

reported

exposed)

Le 2025/2026

Retrospective 218 exposed GLP-1 RA

RGC;

RGC 20.6%; 9 terminated; 1

[

26]

GLP-1 cohort

class

complications aspiration; 1 intraprocedural

intubation

Pai 2026 [27]

Prospective

ultrasound

cohort

316 exposed GLP-1 RA

class

High RGC;

withholding

interval

High RGC 35.8%; shorter

hold/solid fast associated with high

RGC

Vlaeminck 2026 Prospective

87

Semaglutide Full stomach;

solids

Full stomach 49% vs 18% (OR

4.29); solids 42% vs 7%

[

28]

multicenter

matched

analyzable

(43 vs 44)

ultrasound

Ahmad/OCULUS Randomized

026 [29] EGD trial

60

GLP-1/GLP- Clinically

1-GIP; hold significant

vs continue residual

volume

25.0% continue vs 3.1% hold one

dose; no

aspiration/intubation/hospitalization

2

Dong 2026 [30]

Retrospective 16,067 (103 GLP-1 RA

RGC

0.4% no use; 5.83% continue;

1.61% 2-week hold

EGD

continue; 62 class

hold 2 wk)

Chang 2026 [31] Retrospective 3,746

GLP-1 RA

class

Increased

RGC

GLP-1 use independently

associated with RGC; concurrent

colonoscopy evaluated

case-control

EGD

Patel 2026 [32]

Retrospective 150 (73 vs

GLP-1 RA

class

Food retention No significant binary GLP-1

EGD; TiGR

scale

77)

grading

association in this small cohort;

illustrates definition heterogeneity

Abbreviations: EGD, esophagogastroduodenoscopy; GLP-1 RA, glucagon-like peptide-1 receptor

agonist; RGC, retained/residual gastric content; T2D, type 2 diabetes; AE, adverse event. Eight

additional legacy studies were available only as conference abstracts and contribute to the

predecessor pooled benchmark [1] but are not re-extracted here.

3

.2 Overview of the evidence

The integrated evidence domains, principal outcomes, and key estimates are

summarized in Table 2.

Table 2. Integrated overview of ultrasonographic, endoscopic, randomized, and anesthetic

evidence

Evidence domain Evidence base

Primary

Key estimate/finding

Interpretation

outcome

Upper-GI

24 observational

Endoscopic RGC, RGC OR 4.82 (3.66-

Strong surrogate signal;

aspiration rare; very-low

certainty [1]

endoscopy (legacy studies; 184,707

benchmark)

aspiration,

6.35); discontinuation

OR 3.93 (2.42-6.39);

aspiration OR 1.10 (0.84-

participants

discontinuation

1.48)

Controlled gastric

ultrasound

4 pooled cohorts;

n=461

Full stomach /

increased RGC

Pooled crude OR 9.31

(3.68-23.57); I²=60.0%

Consistent direction;

heterogeneous

populations and

definitions

2

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Naranjo-Ramos et al. (2026)

Evidence domain Evidence base

Primary

Key estimate/finding

Interpretation

outcome

Other gastric

ultrasound

Sherwin n=20; Pai

n=316

Solids, volume,

withholding

interval

Semaglutide associated Useful for triage; limited

with more residual solids; direct endoscopy linkage

Pai found high RGC in

35.8% of GLP-1 users

Randomized

withholding

evidence

OCULUS RCT; n=60 Clinically

significant

25.0% continuing vs

3.1% withholding one

dose

First randomized

endoscopy evidence;

small and stopped early

residual gastric

volume on EGD

Post-update

endoscopy cohorts Patel (2025-2026)

Le, Dong, Chang,

RGC, interruption, Generally confirms

aspiration higher RGC, with

No consistent

demonstration of

heterogeneity by obesity, increased aspiration

preparation, and grading

Across modalities, the direction of

effect was consistent for the

surrogate endpoint of gastric

retention. The magnitude varied

because ultrasound studies used a

physiologic full-stomach threshold,

whereas EGD studies used visual,

suction-based, or report-derived

definitions. This distinction precluded

a single combined meta-analysis.

and 19% of controls, with an adjusted

prevalence ratio of 2.48 [10].

Nersessian et al. studied 220

surgical

patients

and

found

increased RGC in 40% of patients

exposed to semaglutide within 10

days versus 3% of controls; there

were no aspiration events [19].

Queiroz et al. reported a full stomach

in 73% of semaglutide-exposed

volunteers versus 7% of controls

despite standard fasting [22]. In the

3

.3 Gastric ultrasound findings

Six newly integrated ultrasound

studies were identified

9,10,19,22,27,28]. Sherwin et al.

2

026 multicenter matched study by

Vlaeminck et al., a full stomach was

present in 49% of semaglutide users

versus 18% of controls, and solid

content in 42% versus 7% [28]. Pai et

al. assessed 316 GLP-1 RA users

before anesthesia and found high

RGC in 35.8%, with shorter

withholding intervals and shorter

solid fasting associated with higher

risk [27].

[

prospectively

evaluated

20

volunteers and found residual solids

after an 8-hour fast in 70% of

semaglutide users versus 10% of

controls in the supine position and

9

0% versus 20% in the lateral

position [9]. Sen et al. prospectively

enrolled 124 fasted procedural

patients; increased RGC was

present in 56% of GLP-1 RA users

2

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Review and Evidence Update of Ultrasonographic, Endoscopic, and Anesthetic Outcomes.

Pooling

the

four

controlled

heterogeneity (I²=60.0%) (Figure 2).

This estimate should be interpreted

as an exploratory class-level

association rather than diagnostic

accuracy.

ultrasound studies with compatible

full-stomach/increased-RGC

definitions (n=461) yielded a crude

random-effects OR of 9.31 (95% CI

3

.68-23.57),

with

substantial

Figure 2. Exploratory random-effects synthesis of controlled gastric-ultrasound studies. Events

represent study-specific full-stomach/increased-RGC definitions.

3

.4 Endoscopic retained gastric

propensity-matched analyses (OR

3.79, 95% CI 2.96-4.84; I²=10%) [1].

content

The most comprehensive endoscopy

synthesis through July 2025 included

The study-level literature shows

clinically relevant heterogeneity.

Silveira et al. reported increased

RGC in 24.2% of semaglutide users

versus 5.1% of controls [8]. Wu et al.

documented visible gastric contents

in 18.9% versus 4.9% and reported

five urgent intubations among GLP-

1-exposed procedures versus one in

controls [11]. Abu-Freha et al.

2

1

4

observational studies and

84,707 participants, 59,095 of

whom were receiving GLP-1 RAs [1].

RGC occurred in approximately

1

2

1.0% of GLP-1 RA users versus

.7% of controls, corresponding to

OR 4.82 (95% CI 3.66-6.35; I²=63%).

The association remained in

2

181

Naranjo-Ramos et al. (2026)

analyzed 120,879 EGDs and found

gastric residue in 5.6% of GLP-1 RA

users versus 2.0% of nonusers [15].

Conversely, more recent studies

using alternative grading systems

have shown lower or nonsignificant

associated with RGC, while longer

interruption in asymptomatic patients

approached the risk of nonusers [18].

Dong et al. reported RGC rates of

5.83% with continued GLP-1

therapy, 1.61% after a 2-week hold,

and 0.4% in nonusers; obesity

remained an independent risk factor

[30]. These studies should not be

binary

emphasizing

standardized definitions [32].

retention

differences,

the

need for

interpreted

as

establishing

a

3

.5 Withholding strategies and

universal cessation interval because

drug formulation, dose escalation,

symptoms, diabetes, obesity, and

baseline gastroparesis differ across

patients.

bowel-preparation effect

The 2026 OCULUS randomized

clinical trial provides the strongest

causal evidence to date. In the

preplanned interim analysis of 60

patients undergoing elective upper

endoscopy, clinically significant

residual gastric volume occurred in

3

.6 Aspiration and anesthetic

outcomes

Despite a consistent increase in

2

1

5.0% of those who continued GLP-

/GLP-1-GIP therapy versus 3.1% of

RGC,

aspiration was rare. In the

predecessor meta-analysis,

clinically

documented

those who withheld one dose [29].

The trial was stopped early after the

aspiration occurred in approximately

0.4% of GLP-1 RA users and 0.1% of

controls; the pooled association was

not statistically significant (OR 1.10,

95% CI 0.84-1.48; I²=9%) [1]. Similar

null estimates were reported by Baig

et al. [2], although another 2025

meta-analysis reported an increased

aspiration signal [3]. The discrepancy

reflects rare events, differing

outcome definitions, claims-based

coding, and cohort overlap.

interim

difference.

Importantly,

participants undergoing EGD with

concurrent colonoscopy and clear-

liquid preparation had no clinically

significant residual-volume events in

either group, supporting the biologic

plausibility of prolonged clear-liquid

preparation as a mitigation strategy.

Santos et al. found that semaglutide

interruption intervals shorter than 8

days and 8-14 days remained

2

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Review and Evidence Update of Ultrasonographic, Endoscopic, and Anesthetic Outcomes.

At the individual-study level, Silveira

et al. and Wu et al. each reported one

aspiration event among exposed

patients [8,11], whereas large

therefore support triangulation of the

same biologic phenomenon—

delayed gastric emptying—but do not

yet establish a validated ultrasound

claims-based

studies

produced

threshold

that

predicts

the

conflicting results. Yeo et al. reported

an association with aspiration

subsequent endoscopic field in GLP-

1-treated patients.

pneumonia

after

endoscopic

3

.8 Methodological quality of

procedures [16], while Alkabbani et

al. found a weighted aspiration risk of

approximately 4.15 versus 4.26 per

newly integrated studies

The structured appraisal of the 11

newly integrated studies identified

serious methodological concerns in

three studies, moderate concerns in

seven, and some concerns in the

randomized OCULUS trial. The

principal concerns were small or

1

000 for GLP-1 RA versus SGLT-2

inhibitor users (RR 0.98, 95% CI

.73-1.31) [17]. Anazco et al.

0

likewise reported a low absolute

incidence of aspiration among

thousands of GLP-1-treated upper

endoscopies [21].

convenience

confounding,

samples, residual

nonrandomized

3

.7

Direct

ultrasound-to-

exposure or withholding strategies,

exposed-only designs, and early trial

stopping. These judgments are

summarized in Table 3 and should

be interpreted as single-reviewer

structured concerns rather than

duplicate-review formal ROBINS-I or

RoB 2 assessments.

endoscopy correlation

No eligible study was identified that

prospectively performed gastric

ultrasound immediately before EGD

in the same GLP-1-treated cohort

and then evaluated prespecified

diagnostic-accuracy

measures

(sensitivity, specificity, likelihood

ratios, or agreement) against

endoscopic gastric contents as the

reference standard. This is the

central evidence gap revealed by the

integrated Existing

review.

ultrasound and endoscopy studies

2

183

Naranjo-Ramos et al. (2026)

Table 3. Methodological concerns in the 11 newly integrated studies

Study

Design

Overall concern Main rationale

Sherwin 2023

Prospective volunteer

US

Serious concern Very small convenience sample; recent

semaglutide initiation; limited generalizability.

Sen 2024

Prospective US

Moderate

concern

Adjusted analysis but residual confounding and

single-center selection remain.

Nersessian 2024

Queiroz 2025

Pai 2026

Prospective US

Moderate

concern

Strong association; nonrandomized exposure and

perioperative selection.

Prospective volunteer

US

Serious concern n=30; volunteer design; wide imprecision.

Prospective US cohort

Moderate

concern

No unexposed comparator; useful for risk-

factor/withholding analysis.

Vlaeminck 2026

Le 2025/2026

Ahmad/OCULUS

Prospective matched US Moderate

concern

Multicenter and matched; residual confounding

and small sample.

Retrospective exposed-

only EGD

Serious concern No comparator; adverse events descriptive only.

Randomized EGD trial

Some concerns

Randomized design; small interim sample and

early stopping may inflate effect size.

2026

Dong 2026

Chang 2026

Patel 2026

Retrospective EGD

Moderate

concern

Large reference group; withholding not

randomized; obesity interaction.

Retrospective case-

control EGD

Moderate

concern

Large screened population; residual confounding

and case-control sampling.

Retrospective EGD

Moderate

concern

Small cohort; novel grading scale; limited power

for rare outcomes.

These ratings reflect a structured single-reviewer appraisal of the update and should not be

interpreted as duplicate-review formal ROBINS-I or RoB 2 judgments.

event that is both rare and vulnerable

4

. Discussion

to

misclassification.

Third,

4

.1 Principal findings

randomized evidence now suggests

that withholding can reduce residual

volume in some patients, while clear-

liquid preparation may substantially

modify risk. Fourth, the key

translational link remains missing:

This integrated review yields four

clinically important conclusions. First,

the association between GLP-1-

based therapy and residual gastric

content is robust across two

direct

paired

validation

of

independent

measurement

preprocedural gastric ultrasound

against subsequent EGD findings.

modalities. The effect is large on

gastric ultrasound and remains

consistently elevated in endoscopic

cohorts. Second, the strength of

association with RGC does not

translate directly into a proven

increase in pulmonary aspiration, an

4

.2 Why ultrasound may be

clinically valuable

Gastric ultrasound has an important

temporal

advantage

over

2

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Review and Evidence Update of Ultrasonographic, Endoscopic, and Anesthetic Outcomes.

endoscopy: it can be performed

before sedation or induction. In a

patient with uncertain medication

timing, ongoing nausea/bloating,

obesity, diabetes, or suspected

gastroparesis, a clear demonstration

of solids or a large fluid volume can

meaningfully alter the risk-benefit

calculation before airway reflexes are

threshold at which those actions

improve net outcomes remains

uncertain.

4

.3 Endoscopy and anesthesia

implications

For

gastroenterologists,

the

consequences of RGC extend

beyond aspiration. Retained food

may impair mucosal visualization,

trigger procedure abortion, and

require repeat EGD [12-15]. For

anesthesiologists, the same finding

changes the airway-risk profile and

may favor deferral, rapid-sequence

induction with tracheal intubation, or

suppressed.

The

2025

ADS/ANZCA/GESA/NACOS

recommendations explicitly endorse

a 24-hour clear-fluid diet followed by

standard fasting and recommend

gastric ultrasound or minimally

sedated gastroscopy when that

preparation has not been completed

other

individualized

strategies

[

4]. Multisociety guidance similarly

depending on urgency and patient

comorbidity. The decision should

therefore be shared across the

procedural team rather than reduced

to a medication hold/no-hold rule.

supports individualized risk

assessment rather than automatic

discontinuation for every patient [5].

However, ultrasound should not be

framed as a proven aspiration-

prevention intervention. Current

studies validate association with

gastric content, not a reduction in

The apparent protective effect of

concurrent colonoscopy seen in

several cohorts and in the OCULUS

trial is mechanistically plausible

because bowel preparation usually

imposes a prolonged clear-liquid

period. This signal supports research

into preparation-based mitigation

rather than simply extending drug-

withholding intervals, particularly for

aspiration

events.

Operator

dependence, body habitus, altered

gastric anatomy, and inconsistent

volume equations also limit universal

implementation. A positive scan may

appropriately prompt postponement

or airway protection, but the

long-acting

agents

whose

2

185

Naranjo-Ramos et al. (2026)

pharmacodynamic

effects

may

before upper endoscopy is presented

in Table 4. It is intended to support

individualized discussion between

gastroenterology and anesthesia

teams rather than to function as a

validated prediction rule.

persist beyond one missed weekly

dose.

An evidence-informed framework for

multidisciplinary

decision-making

Table 4. Evidence-informed clinical interpretation framework for GLP-1-treated patients

undergoing upper endoscopy

Step

Action

Interpretation

1

Identify exposure

Ask specifically about GLP-1 RA/GLP-1-GIP agent, dose, escalation

phase, last dose, indication, GI symptoms, diabetes, obesity,

gastroparesis, opioid use.

2

3

Optimize preparation

When feasible, use a 24-hour clear-fluid strategy plus standard fasting

according to local guidance.

Use gastric POCUS when Visible solid/thick content or clearly elevated fluid volume indicates a

uncertainty remains

higher-risk stomach; an apparently empty/low-volume stomach lowers but

does not eliminate aspiration risk.

4

5

Coordinate endoscopy +

anesthesia plan

If high-risk content is detected, individualize deferral versus protected-

airway general anesthesia according to urgency and patient risk.

Avoid overreliance on

symptoms

Absence of nausea/bloating does not reliably exclude increased gastric

content in GLP-1-treated patients.

This table summarizes current evidence and multidisciplinary guidance [4,5]; it is not a validated

clinical prediction rule.

specificity,

likelihood

ratios,

4

.4 Proposed research agenda

calibration of estimated gastric

volume, and agreement. Secondary

analyses should evaluate whether

The highest-priority next study is a

prospective paired diagnostic-

accuracy cohort in GLP-1-treated

adults undergoing elective EGD.

Gastric ultrasound should be

ultrasound

changes

anesthetic

management, procedure completion,

and airway events.

performed

immediately

before

A subsequent pragmatic trial should

sedation using

a

prespecified

compare

ultrasound-guided

qualitative/quantitative protocol; the

gastroenterologist should then grade

solid and liquid gastric content using

a standardized endoscopic scale

while blinded to the ultrasound result

whenever feasible. Primary analyses

management with a standardized

preparation strategy (for example,

2

4-hour clear liquids plus standard

fasting) using clinically relevant

outcomes and decision-impact

measures. Given the rarity of

should

estimate

sensitivity,

2

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Review and Evidence Update of Ultrasonographic, Endoscopic, and Anesthetic Outcomes.

aspiration, multicenter recruitment or

a composite endpoint including

susceptibility to reviewer-dependent

classification. Third, most evidence

remains observational, with

regurgitation,

intervention,

urgent

and

airway

procedure

heterogeneous fasting protocols,

exposure definitions, GLP-1 agents,

and RGC thresholds. Fourth, the

exploratory ultrasound meta-analysis

uses crude event counts and

includes small cohorts. Fifth,

aspiration events are too rare for

precise effect estimates. Finally, the

absence of a paired ultrasound-EGD

validation study prevents claims of

diagnostic accuracy or direct

correlation between modalities.

interruption may be required.

4

.5 Strengths and limitations

A key strength of this work is its

explicit integration of imaging,

gastroenterology, and anesthesia

evidence, including new 2026

randomized

and

prospective

ultrasound data that are not the

central focus of prior endoscopy

meta-analyses. separate

quantitative synthesis of compatible

ultrasound cohorts avoids

The

5

. Conclusiones

inappropriate pooling of ultrasound

and endoscopic definitions. The

GLP-1 receptor agonist and dual

GLP-1/GIP therapy is strongly

associated with retained gastric

content detected by both gastric

evidence-update

design

also

minimizes unnecessary duplication

of a recent 24-study endoscopy

meta-analysis.

ultrasound

and

upper

In

gastrointestinal

endoscopy.

Several limitations are important.

First, this is a structured update

controlled ultrasound cohorts, GLP-1

exposure was associated with

approximately ninefold higher crude

odds of a full stomach/increased

anchored

to

a

predecessor

not an

systematic

review,

independently repeated search of

every bibliographic database.

RGC,

while

the

established

shows

endoscopy

evidence

Second, the update screening and

methodological appraisal were not

independently duplicated by two

approximately fivefold higher odds of

RGC. In contrast, the absolute

incidence of aspiration is low and

reviewers,

which

increases

2

187

Naranjo-Ramos et al. (2026)

current studies do not provide a

consistent estimate of excess clinical

risk. Gastric ultrasound is therefore

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residual gastric content and

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