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Gastroparesis and Diabetes
Gastroparesis is seen in patients with both type 1 and type 2 diabetes and means that the stomach takes too long to empty its contents.
There are many types of diabetic autonomic neuropathy, including resting tachycardia, exercise intolerance, orthostatic hypotension, constipation, gastroparesis, erectile dysfunction, sudomotor dysfunction, impaired neurovascular function, "brittle diabetes," and hypoglycemic autonomic failure, according to the American Diabetes Association's (ADA) Position Statement: Standards of Medical Care in Diabetes.1
The neuropathy gastroparesis is seen in patients with both type 1 and type 2 diabetes and means that the stomach takes too long to empty its contents. According to the ADA Web site, this happens when nerves to the stomach are damaged or stop working.2 The vagus nerve controls the movement of food through the digestive tract; therefore, if damaged, the muscles of the stomach and intestines do not work normally, and the movement of food is slowed or stopped.
Gastrointestinal (GI) neuropathies (eg, esophageal enteropathy, gastroparesis, constipation, diarrhea, fecal incontinence) are common and can affect any portion of the GI tract. The ADA statement said that gastroparesis should be suspected in individuals with erratic glucose control or with upper-GI symptoms without other identified cause. Evaluation of solid-phase gastric emptying using double-isotope scintigraphy may be done if symptoms are suggestive, but test results often correlate poorly with symptoms. Constipation is the most common lower-GI symptom but can alternate with episodes of diarrhea.
Signs and symptoms of gastroparesis, which can be mild or severe, are:
- heartburn
- nausea
- vomiting of undigested food
- an early feeling of fullness when eating
- weight loss
- abdominal bloating
- erratic blood glucose (sugar) levels
- lack of appetite
- gastroesophageal reflux
- spasms of the stomach wall
COMPLICATIONS OF GASTROPARESIS
Gastroparesis makes diabetes worse because it complicates blood glucose management. When food that has been delayed in the stomach finally enters the small intestine and is absorbed, blood glucose levels rise. If food stays too long in the stomach, it can cause problems such as bacterial overgrowth because the food has fermented, according to the ADA Web site. Also, the food can harden into solid masses called bezoars that may cause nausea, vomiting, and obstruction in the stomach. Bezoars can be dangerous if they block the passage of food into the small intestine.
DIAGNOSIS
Gastroparesis is diagnosed through one or more of the following tests.
Barium x-ray. After a 12-hour fast, the patient drinks a thick liquid containing barium which makes the stomach visible on x-ray. Normally, the stomach is empty following 12 hours of fasting. If the x-ray reveals food in the stomach, gastroparesis is likely. If the x-ray shows an empty stomach and delayed emptying is still suspected, then a repeat test is given. On any one day, a person with gastroparesis may digest a meal normally, giving a falsely normal test result.
Barium beefsteak meal. A meal that contains barium is administered to the patient, allowing the physician to watch the stomach digest the meal. The time it takes for the barium meal to be digested and leave the stomach gives the clinician an indication of how well the stomach is working. This test can help find emptying problems that do not show up on the liquid barium x-ray. Individuals with diabetes-related gastroparesis often digest fluid normally, so the barium beefsteak meal can be more useful, according to the ADA.
Radioisotope gastric-emptying scan. The patient ingests food that contains a radioisotope (the dose of radiation small and not dangerous). After eating, the patient lies under a machine that detects the radioisotope and shows an image of the food in the stomach and how quickly it leaves the stomach. Gastroparesis is diagnosed if more than half of the food remains in the stomach after 2 hours, the ADA said.
Gastric manometry. This test measures electrical and muscular activity in the stomach. A thin tube containing a wire that measure the stomach's electrical and muscular activity as it digests is passed down the patient's throat into the stomach. The measurements indicate how well the stomach is working and if there is a delay in digestion.
Blood tests. Laboratory tests may be ordered to check blood counts and to measure chemical and electrolyte levels.
To rule out causes of gastroparesis other than diabetes, an upper endoscopy or an ultrasound may be performed.
The ADA states that the most important treatment goal for diabetes-related gastroparesis is to manage blood glucose levels as well as possible. Treatments (Table 1) include insulin, oral medications, changes in diet and eating times, and, in severe cases, feeding tubes and intravenous feeding may be needed.
INSULIN FOR BLOOD GLUCOSE CONTROL
To better manage blood glucose, patients may need to change their insulin regimen to take insulin more often and after meals. Frequent blood glucose monitoring is needed after meals and after insulin administration whenever necessary.
Medication. Several drugs are used to treat gastroparesis. Different drugs or combinations of drugs may be used to find the most effective treatment.
Meal and food changes. Changing eating habits can help control gastroparesis. A dietitian can provide specific instructions, such as eating six small meals a day instead of three large ones. Liquid meals may be recommended until blood glucose levels are stable and the gastroparesis has improved. Patients may be instructed to avoid high-fat and high-fiber foods.
Feeding tube. If other approaches do not work, surgery to insert a feeding tube may be necessary. A jejunostomy is particularly useful when gastroparesis prevents the nutrients and medication necessary to regulate blood glucose levels from reaching the bloodstream. Avoiding the source of the problem (the stomach) and putting nutrients and medication directly into the small intestine ensures that these products are digested and delivered to the bloodstream quickly. A jejunostomy tube can be temporary and is used only if necessary when gastroparesis is severe.
It is important to note that in most cases, treatment does not cure gastroparesis—it is usually a chronic condition. Treatment helps patients manage gastroparesis, so that they can be as healthy and comfortable as possible.
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