Here on blogdiabetes.com we have shared information about many of the long and short term complications of diabetes and this month we describe gastroparesis. “Gastro” means stomach and “paresis” means impairment or paralysis.
Diabetic gastropathy is a term for the spectrum of neuromuscular abnormalities of the stomach. The abnormalities include gastric-dysrhythmias, antral hypomotility, incoordination of antroduodenal contractions and gastroparesis. The stomach is a neuromusclar organ that receives the food we ingest, mixes the food with acid and pepsin and empties the nutriment suspension into the small intestine for absorption.
The proximal stomach or fundus relaxes in order to receive the swallowed food. i.e. receptive relaxation. The body and antrum mix and empty the food via recurrent gastric peristalic waves. The peristaltic contractions are paced by neoelectrical events called pacesetter potentials or slow waves.
When gastric motility is normal, the postprandial (after eating) period is associated with pleasant epigastric sensations. Gastric motility disorders or gastroparesis presents with unpleasant, but non-specific postprandial symptoms: upper abdominal bloating, distention, discomfort, early satiety, nausea and vomiting. If the vomitus contains undigested food then gastroparesis is very likely to be present. Fluctuating, difficult-to-predict glucose levels may also reflect the presence of gastroparesis.
The motility of your GI tract, which we were just speaking of, is controlled by an outer sleeve of muscles that surrounds your GI tract They are controlled by a complex nervous system. Diabetes can damage these nerves and it is this neurological long term complication of diabetes that can lead to gastrointestinal disorders.
How do we know this is the case? First, many of the people with gastroparesis have long-standing diabetes and evidence of damage to other organs. Second, many of these people have other symptoms of neuropathy (nerve damage), such as painful hands and feet, abnormal swings in blood pressure, and unusual sweating after eating. Finally, there are cases of people without diabetes who have their nerves cut and they develop the symptoms of the disease.
Nerve damage occurs over the course of years. But even people who haven’t had diabetes for a long time can develop gastroparesis. A clear example is the person who develops diabetic ketoacidosis and experiences the symptoms of this disease including nausea, vomiting and abdominal pain. Professionals now think that even short-term hyperglycemia may cause problems of the GI tract.
So now let’s look at how gastroparesis can present itself. If you have this problem the grinding function of the stomach is greatly reduced or lost. Food can’t be broken up into smaller pieces and doesn’t move on to the intestines and bowel normally. Food stays in the stomach much longer than normal. The symptoms of gastroparesis are:
- vomiting up partially digested food that has been sitting in your stomach
- dry heaves
- abdominal bloating
- abdominal pain
- loss of appetite
- the feeling of filling up too quickly while eating
You can imagine a real problem of this complication is vomiting as it makes regulation of diabetes very difficult. Dehydration is difficult for diabetics. It can lead to diabetic ketoacidosis. Persistent vomiting can also make the lining of your stomach bleed. Because the food you eat remains in your stomach too long, vomiting may bring up food from a just eaten meal as well as food eaten up to 24 hours before. Some people with this condition vomit even when their stomach is empty as when they wake in the morning.
The scary thing about gastroparesis is that a person with the condition may be perfectly fine for days or weeks at a time but then have hours or days of vomiting that will lead to hospitalization. Or you may have nausea that lasts all day, bloating and little appetite, but no vomiting. It is also possible to have none of the classic symptoms, but instead have wild swings in blood glucose levels due to the fact that insulin intake does not match food intake because food remains in the stomach for long periods of time.
Gastroparesis is diagnosed by upper gastrointestinal X-rays, and a gastroscopy which allows the doctor to look into the stomach with a scope that contains a tiny camera. Other tests may be initiated. All of these will help rule out other diseases such as ulcers, gastritis, and stomach cancer. It is thought that as many as 50% of diabetics may show signs of gastropareisis, but only a small percentage of those people develop symptoms that need intervention.
Treatment begins with a renewed commitment to tight blood glucose control as hyperglycemia aggravates gastoparesis, and hypoglycemia often results from it. This is easier said than done as food is absorbed at unpredictable times making control difficult. High blood glucose levels can slow stomach emptying and that adds to the problem.
If you take insulin, you may be asked to up the number of injections you take daily. You will have to take your blood glucose levels more frequently after you eat to help bring them down with insulin. Your doctor may suggest that you eat small meals throughout the day rather than a few larger ones.
This helps your stomach from becoming overfilled. You will be told to cut back on fatty foods because fat slows stomach emptying. You may also need to cut back on difficult-to-digest foods such as legumes, lentils and citrus fruits. Indigestables may form “tumors of food” known as bezoars. These bezoars will worsen symptoms of fullness, nausea, and abdominal discomfort, and they can be very difficult for a doctor to remove.
Now comes the difficult decision for people with diabetes who suffer from diarrhea or constipation who are advised to eat a high fiber diet. It may seem that the advice to avoid indigestibles contradicts that suggestion. Indigestibles are not exactly the same as high fiber foods, although indigestibles are almost always examples of high-fiber foods. You may have to decide which problem – the stomach symptoms, or the diarrhea and constipation – is worse, when deciding whether or not to eat a high-fiber diet.
Drug treatment is usually necessary for people with significant symptoms. The drug of choice is metoclopramide (Reglan) which acts on the nervous system to increase the strength and frequency of gastrointestinal muscle contractions. It is taken 20 to 30 minutes before meals and at bedtime.
Unfortunately, about 20 percent of those taking the medication develop annoying side-effects of drowsiness, lethargy, depression and/or anxiety. It should not be used by people with Parkinson’s disease. Another medication, domperidone (Motilium) improves stomach emptying by stimulating stomach motor activity.
It is an excellent anti-nausea medication, and unlike metoclopramide, it doesn’t have many side effects. Your doctor may prescribe erthromycin, an antibiotic, which improves stomach emptying quite effectively. It does have side effects of nausea, vomiting and abdominal cramping so that its use may be limited. Another class of medication to talk over with your physician is bethanecol (Urecholine, Duvoid, and Myclonachol).
If a combination of medications or a change of your medication doesn’t work, you may need surgery to have food bypass your stomach. The most popular option is a jejunostomy tube. A small feed tube is placed through the skin into the bowel. When a person with gastroparesis is having a having a bad spell of nausea and vomiting which makes eating or drinking impossible, liquid nitration, fluids, and medication can be delivered through the feeding tube.
A less desirable alternative is to bypass the GI tract all together and place a semi-permanent intravenous line for feeding directly into the bloodstream. Depending on symptoms these alternate feeding methods can be used as a back-up during periods when the person can not eat, or as a more regular means of nutritional support.
According to the experts it is difficult to predict when a diabetic’s gastroparesis will get better. Some people with the disease will have to be hospitalized regularly. After some months or years, the disease seems to burn itself out and the person improves. Other people are bothered by less annoying symptoms that continue for many years.
If you think you have gastroparesis, don’t give up. If your generalist can’t control the symptoms, it may be necessary to see a gastroenterologist, a specialist in stomach disorders. Luckily, with proper diagnosis, treatment, and time, symptoms can usually be controlled. Now that you understand this complication of diabetes you can more easily talk over your symptoms and ask questions about medications and interventions. You can be helped, so don’t suffer in silence.