What is Diabetic Gastroparesis?
Gastroparesis is a condition where the stomach takes too long to empty its contents, and there’s no clear physical blockage causing it. Diabetic gastroparesis is a specific type that can happen when diabetes is not well-managed. This issue stems from problems with the automatic nervous system, nerve cells, unique pacemaker cells (also known as interstitial cells of Cajal, ICC) in the stomach and intestines, and the muscle cells in the digestive tract.
What Causes Diabetic Gastroparesis?
High blood sugar levels, also known as hyperglycemia, is often seen in people who have poorly managed diabetes. This high blood sugar can be linked to a condition called diabetic gastroparesis, which involves the stomach taking too long to empty its contents. This happens because of nerve damage due to chronic high blood sugar levels. Notably, this doesn’t get better with improved control of blood sugar. However, short-term high blood sugar can also cause a delay in the stomach emptying, but this issue often improves when blood sugar is better controlled.
The process of the stomach emptying food requires a balanced interaction of stomach muscles and nerves, as well as specialized cells in the stomach that act like pacemakers (called myenteric interstitial cells of Cajal; ICCs). In people with diabetes, this dynamic process can be disrupted due to nerve damage, abnormalities in ICCs, shifts in blood sugar levels, certain medications, and even emotional stress. As a result, many people with diabetes have problems at various stages of the stomach emptying process. This includes abnormal movement and regulation in different parts of the stomach after eating.
Risk Factors and Frequency for Diabetic Gastroparesis
Gastroparesis, a condition that slows the movement of food from the stomach to the small intestine, is often found in people with diabetes, though it can also occur without a known cause, which is called idiopathic gastroparesis. Certain symptoms common in the upper part of the digestive tract such as bloating, fullness, and nausea, are reported in 11% to 18% of people with diabetes. These symptoms are frequently due to gastroparesis. Specifically, gastroparesis affects about 4.8% of those with type 1 diabetes and 1% with type 2 diabetes. Even though it is seen more in people with type 1 diabetes, type 2 diabetes is a lot more common so there are actually more total cases of gastroparesis in people with type 2 diabetes.
The use of a certain group of medications known as “incretin mimetics” for type 2 diabetes can increase the risk of developing gastroparesis. If a diabetic patient has been experiencing signs and symptoms of slow stomach emptying, it’s more commonly seen in those with type 1 diabetes and typically in those who have had diabetes for at least five years. In most cases, gastroparesis tends to show up in people who have known they have diabetes for at least ten years. Due to this, it often appears in older individuals with type 2 diabetes.
- Most cases of gastroparesis are idiopathic, but diabetes is the most common associated disease.
- 11% – 18% of people with diabetes report upper gastrointestinal symptoms related to gastroparesis.
- Gastroparesis affects approximately 4.8% of individuals with type 1 diabetes and 1% of those with type 2 diabetes.
- Gastroparesis appears more often in type 1 diabetic patients, but it is also seen in type 2 diabetic patients as this disease is more common.
- Incretin mimetics, used in treating type 2 diabetes, can increase the risk of gastroparesis.
- Symptoms are more common in those who have had diabetes for at least five years, usually showing up in those who’ve known they have diabetes for at least ten years.
- Due to the time it takes for symptoms to appear, it’s often seen in older individuals with type 2 diabetes.
Signs and Symptoms of Diabetic Gastroparesis
Gastroparesis often leads to several symptoms, with nausea being the most common. Other frequent symptoms include vomiting, feeling full quickly when eating, a sense of fullness after meals, and bloating. Sometimes, the vomit may contain pieces of not fully digested food. This condition can cause sufferers to lose or gain weight, and it can also cause blood sugar levels to fluctuate wildly. These symptoms often relate to meal times.
Physical exams for gastroparesis don’t usually show anything specific but may reveal nerve damage, a bloated abdomen, or bad breath. These signs are common in people with diabetes-induced gastroparesis.
Several factors can worsen diabetic gastroparesis. They include high blood sugar levels, not taking prescribed medication, having a negative reaction to medication, adrenal insufficiency, and infections.
- Nausea
- Vomiting
- Feeling full quickly when eating
- Feeling of fullness after meals
- Bloating
- Weight loss or gain
- Fluctuating blood sugar levels
- Symptoms related to meal times
- Possible nerve damage
- Bloating
- Bad breath
Testing for Diabetic Gastroparesis
If a patient comes in with symptoms suggesting potential stomach issues, the first step doctors take is to rule out certain conditions like mechanical obstruction and peptic ulcer disease. To do this, they first perform an upper gastrointestinal endoscopy, a procedure that allows them to view the upper part of the digestive tract. Following this, they may carry out a CT scan with oral and intravenous contrast or another type of imaging to ensure there’s no blockage beyond the first part of the small intestine, called the duodenum. If they see food remaining on the endoscopy without a mechanical blockage, it’s often a sign of a condition called gastroparesis.
To diagnose gastroparesis, which is a condition where the stomach isn’t able to empty properly, doctors often use a test called gastric emptying scintigraphy. This is a popular and cost-effective test that allows doctors to measure how quickly food leaves the stomach. It involves eating a meal containing a small, safe amount of radioactive material, then taking images at different times to see how quickly the meal is being digested. It’s important to note that certain medications and high blood sugar can affect the rate at which your stomach empties, so doctors might adjust these factors before the test to get the most accurate results.
The breath test is another method used to diagnose gastroparesis. This test uses a special type of fat, called octanoate, that’s connected to a solid meal. Once the meal leaves the stomach, the fat is absorbed into the small intestine and turned into a type of carbon dioxide that’s detected when you breathe out. This test is usually done for research purposes and not as commonly used in general clinical practice.
There are also tests based on the electrical activity of the gut, like electrogastrography and gastroduodenal manometry, that could potentially be useful for diagnosis. However, these are currently not widely available for general use.
Treatment Options for Diabetic Gastroparesis
The initial treatment for gastroparesis, a condition where the stomach empties too slowly, often includes lifestyle changes. If you have diabetes, keeping your blood sugar levels under control can lessen the impact of high blood sugar, which can further delay stomach emptying. Common advice includes eating smaller, more frequent meals, reducing the intake of fizzy drinks, incorporating more liquids in your food, and reducing fats and fiber. You should also avoid alcohol and smoking as they can make the symptoms worse.
Medicines that combat nausea and vomiting, like ondansetron, prochlorperazine and promethazine, are often the first step in treating gastroparesis. However, they might cause tiredness and coordination issues, and so they’re usually used as needed.
A cornerstone of treatment for diabetic gastroparesis includes prokinetic agents, medicines intended to speed up the movement of the stomach muscles. One commonly used drug is metoclopramide which increases the contractions of the stomach muscles. It can be effective for several weeks, but the results can be inconsistent with long-term use. Erythromycin, which can trigger movement in the upper gut, is another short-term solution, but its effectiveness can wear off over time.
Domperidone, similar to metoclopramide, is less likely to cause coordination issues. It can provide relief for about six weeks in individuals with diabetes. However, it has previously been linked with heart rhythm issues and is not approved for sale in the USA. Another drug, Cisapride, which could provide relief for up to a year, was withdrawn from the US market due to its link to serious heart rhythm problems. Both these drugs can be accessed through clinical trials with thorough patient monitoring.
If the above treatment options don’t work, a combination of prokinetic therapies or managing nausea with anti-nausea medicine might be an alternative. Some studies recommend injections to relieve symptoms, but these studies were often small and not blinded.
Gastric electrical stimulation, while studied, has not shown consistent symptom relief across the board. While approved by the FDA, it’s not widely available. In severe cases, a gastrostomy tube can be inserted for relief, or in instances where oral intake is not possible, a feeding jejunostomy can be implanted to provide nutrition, fluids and electrolytes.
The last option in severe cases of gastroparesis is surgery, such as a partial gastrectomy with Roux-en-Y gastrojejunostomy and gastric resection. However, there is not enough data on surgical treatment at this time, and it’s ideal for a specialist to make this decision.
What else can Diabetic Gastroparesis be?
When diagnosing gastrointestinal issues, doctors often might consider the following conditions that could be causing the symptoms:
- Stomach obstruction (Gastric outlet obstruction)
- Repetitive regurgitation of food (Rumination syndrome)
- Indigestion that stays longer than usual (Functional dyspepsia)
- Persistent inflammation of the pancreas (Chronic pancreatitis)
- Persistent severe pain caused by the blockage in the gallbladder (Biliary colic)
Each of these conditions has symptoms that can be similar, but they require different treatments. That’s why it is important for medical professionals to conduct thorough examinations and tests to determine the correct diagnosis.
What to expect with Diabetic Gastroparesis
The results of diabetic gastroparesis – a condition that affects the stomach muscles – are unclear. Its outlook largely depends on how well a person can control high blood sugar levels and adhere to their medication regimen. This condition can significantly affect the quality of life and can cause severe health problems if not managed well.
It’s crucial for people to understand that this is a lifelong condition that needs continual management. This understanding is key for improving the patients’ overall health condition.
Possible Complications When Diagnosed with Diabetic Gastroparesis
Malnutrition is a significant issue that can arise as a sequela of diabetic gastroparesis and often requires management through various methods such as the creation of a feeding hole in the stomach (jejunostomy), receiving nutrition through a vein (parenteral nutrition), or even surgery. Additionally, diabetic gastroparesis can cause significant changes in blood sugar levels, possibly leading to issues like dangerously low blood sugar (hypoglycemia), a severe diabetes complication due to lack of insulin in the body (diabetic ketoacidosis) or a life-threatening diabetes complication that occurs when your body can’t produce enough insulin (hyperosmolar hyperglycemic state). Other problems like nausea and vomiting can potentially cause a lung infection caused by inhaling vomit (aspiration pneumonia).
Preventing Diabetic Gastroparesis
It’s crucial for patients to understand that this disease is long-term and often irreversible. Careful management is key, including sticking to a specific diet for the condition, using medications sensibly, and keeping blood sugar levels under tight control. These are factors that patients can control, and they can make a significant difference in the progression of the disease and in preventing complications. Advice and guidance from a specialist in diabetes can go a long way in improving the results of treatment for this disease.
