Diabetic gastroparesis is a severe complication resulting from uncontrolled diabetes that impairs quality of life. Dr Louise Johnson expands on this debilitating condition.
Gastroparesis definition
Gastroparesis is characterised by delayed gastric (stomach) emptying in the absence of mechanical obstruction. This is associated with uncontrolled diabetes. It is more prevalent in Type 1 diabetes than in type 2 diabetes.1
Clinical
The prevalence of diabetes associated gastrointestinal symptoms are 5-12%. In a study, done in Olmsted County, Minnesota, the prevalence of gastroparesis in Type 1 diabetes was 5% and in Type 2 diabetes the prevalence was 1%. 2
Gastroparesis is a form of autonomic neuropathy (nerve damage) and is most common seen in people with diabetes longer than 10 years. They usually have microvascular (small blood vessel) complications to the eye, kidney and feet as well.
The most common symptoms are nausea, bloating, abdominal pain and vomiting. The reason for these symptoms is due to delayed pass through of food and liquids from the stomach to the bowel. This is usually due to long-standing poor glycaemic control.
What causes the delay?
In the stomach there are specialised cells called Cajal cells that function as the electrical pacemaker of the stomach. Due to high blood glucose these cells are damaged, and this leads to gastroparesis.
The symptoms of gastroparesis can range from mild to severe and incapacitating. The diagnosis is not always easy as early on a person may be asymptomatic. Early symptoms are early satiety, weight loss, abdominal pain, bloating, nausea and vomiting.
Pain is under-reported and up to 75% of patients with gastroparesis experience abdominal pain.
In a study3 that looked at gastroparesis trends from 1995 to 2004, a 53% increased risk of diabetes-related hospitalisations was attributed to gastroparesis. This condition may also indicate a higher risk of other diabetes-related complications.
Some patients with diabetes may not realise that they experience delayed gastric emptying but exhibit unpredictable responses to mealtime insulin. These responses result from a mismatch between food absorption from the stomach that is slowed down and insulin absorption that is not slowed down. The result is hypoglycaemia early after a meal and a few hours later an unpredictable hyperglycaemia.
In Type 2 diabetes patients who take Glucagon-like peptide-receptor agonists (GLP1 RA), such as exenatide, liraglutide, dulaglutide, semaglutide, the symptoms may be exacerbated since these drugs cause gastric (stomach) delay. This is used in Type 2 diabetes that have increased stomach emptying and tend to overeat and pick up weight.
Diagnosis
The typical complaint associated with gastroparesis is a feeling of excessive fullness after eating, which can last for hours or even overnight. Patients may also complain of feeling full or satiated sooner than expected. When symptoms progress some may even vomit undigested food hours after eating. These symptoms can occur after any meal.
The first test to do is a gastroscopy (swallowing of the camera) to rule out stomach outlet obstruction. Once a mechanical obstruction is ruled out the next step is to measure the time it takes for food to move from the stomach to the small bowel. This is called a gastric motility test.
Patients fast overnight and are not allowed to drink alcohol the night before. Blood glucose should also be below 15 mmol/L. The patient then eats a low-fat egg-white sandwich and special images of the transit time of the food are taken up to 4 hours after eating. When the test is completed and there is more than 10% food left in the stomach after 4 hours, the diagnosis of delaying gastric emptying or gastroparesis is made.
Treatment of diabetic gastroparesis
Non-pharmacological
The first line of treatment for gastroparesis includes dietary modification, glucose control and restoration of fluids and electrolytes.
Foods that are spicy, acidic and fatty should be avoided or minimised because they may worsen symptoms. Carbonated beverages can aggravate the distension of the stomach. Smoking and alcohol slow down stomach movement and should also be avoided. It is suggested to visit a dietitian and eat smaller, more frequent meals.
In more severe cases, feeding needs to be substituted by liquid feeds and in very severe cases hospitalisation and feeding via an intravenous line (drip).
It can be quite challenging to control blood glucose in a person with gastroparesis. It may be necessary to change the mealtime insulin by giving it after a meal to prevent hypoglycaemia. In certain cases, the use of an insulin pump and sensor is very effective by giving small doses of insulin as needed and suspend insulin when blood glucose will go low.
Pharmacological
- Metoclopramide before each meal will help with faster emptying of the stomach.
- Domperidone before each meal will help with faster stomach emptying.
- Erythromycin three times a day before each meal help with stomach emptying but this can’t be used longer than four weeks. It can also aggravate nausea.
- Surgically there is a pacemaker that can be implanted in the stomach to help restore the stomach functions. This is unfortunately very expensive and still very new therapy.
Diabetic gastroparesis is a severe complication resulting from uncontrolled diabetes that impairs quality of life and increases comorbid conditions and mortality. Remember that good glucose control can prevent this complication. It is important to take care of your diabetes and know your numbers (HbA1c). Seek the help of a specialist team to optimise your health and all your diabetes complications.
References
- Krishnasamy S, Abel TL “Diabetic gastroparesis principles and current trends in management.” Diab Ther 2018;9 p1-42
- Jung HK, Choung RS et. al. “The incidence, prevalence and outcomes of patients with gastroparesis in Olmsted County, Minnesota from 1996 to 2006” Gastroenterology 2009;136: 1225-1233
- Wang YR, Fisher RS et. al. “Gastroparesis -related hospitalizations in the United States: trends, characteristics, and outcomes, 1995-2004” Am J Gastroenterology 2008;103:313-322
MEET THE EXPERT
Dr Louise Johnson is a specialist physician passionate about diabetes and endocrinology. She enjoys helping people with diabetes live a full life with optimal quality. She is based in Pretoria in private practice.
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