What Do You Need to Know About Diabetic Gastroparesis?
Author:
Kim A. Carmichael, MD—Series Editor
Citation:
Carmichael KA. What do you need to know about diabetic gastroparesis? Consultant. 2018;58(10):281-282.
Q. What are the common clinical manifestations and complications of diabetic gastroparesis?
A. Gastroparesis is defined by a combination of symptoms plus documented delay in gastric emptying in the absence of any evidence of mechanical obstruction.1 Diabetic gastroparesis is commonly associated with nausea, vomiting, postprandial fullness, bloating, and early satiety.1-3 Although it is more frequently associated with idiopathic gastroparesis, abdominal pain is common in diabetic gastroparesis, is exacerbated by eating, and often interferes with sleep. Gastroparesis may increase the symptoms of gastroesophageal reflux disease and often will be refractory to acid-reducing medication.
In persons with diabetes, gastroparesis may be associated with hypoglycemia, weight loss, anorexia, and malnutrition.2-4 A recent analysis estimated that approximately 35% of peak postprandial glucose excursion is modulated by the rate of gastric emptying.4
Q. How common is diabetic gastroparesis, and what are the risk factors?
A. The prevalence of gastroparesis in tertiary care centers is estimated to be approximately 40% among persons with type 1 diabetes, 10% to 20% among persons with type 2 diabetes, and less common among people without diabetes.1 In the general community, the 10-year incidence is estimated to be 5.2% in type 1 diabetes and 1% in type 2 diabetes.
Markedly uncontrolled diabetes (ie, blood glucose levels > 200 mg/dL) and motility-affecting medications (eg, anticholinergic and narcotic agents, pramlintide, glucagon-like peptide-1 agonists) will often exacerbate symptoms. Of note, dipeptidyl peptidase-4 inhibitors do not affect gastric emptying.
Some patients may present with gastroparesis after viral illness. Symptoms are not directly related to the gastric emptying rate but are more common in the presence of anxiety and depression.
Persons with gastroparesis should be screened for thyroid, autoimmune, or neurologic disorders and a history of prior gastrointestinal surgery.1
Q. How does one make the diagnosis of gastroparesis?
A. In order to distinguish gastroparesis from other gastrointestinal tract diseases, particularly conditions associated with accelerated gastric emptying, the diagnosis must be confirmed by documenting delayed gastric emptying.1,3 This is most commonly done by way of scintigraphic evidence of retention of solids at 4 hours. Wireless capsule motility testing and urea breath testing are less reliable. Functional ultrasonography may also be considered for diagnosis.2
In all cases, medications that affect gastric emptying need to be stopped at least 48 hours in advance, and glycemic control should be optimized.
Q. What is the differential diagnosis for diabetic gastroparesis?
A. Rumination syndrome and eating disorders must be considered, although in patients with these conditions, the regurgitation often occurs within 15 minutes of starting meal, compared with gastroparesis in which regurgitation tends to occur significantly later.1 Cyclic vomiting syndrome may have similar symptoms but is usually associated with rapid gastric emptying during the symptom-free period. Use of cannabinoid agents may also be associated with symptoms similar to gastroparesis. Chronic pancreatic enzyme insufficiency may cause gastrointestinal bloating but is not associated with delayed gastric emptying.
Rarer causes of nondiabetic gastroparesis include neurologic disease (such as parkinsonism, amyloidosis, paraneoplastic disease), gastric infiltrative disease (such as sarcoidosis), or mesenteric ischemia.1
Q. What medical management options are available for diabetic gastroparesis?
A. The first recommendations are to stop medications that slow gastric motility and to optimize glycemic control.1,3 Persons should avoid alcohol, tobacco, and carbonated beverages.
In more advanced cases, one should restore fluids and electrolytes, provide nutritional support (preferably enteral), and provide nutrition counseling.1,3 This involves frequent small-volume meals that are low in fat and soluble fiber, and it may require liquid or homogenized meals. In even more severe instances, postpyloric enteral feeding may be necessary.
Prokinetic therapy is often beneficial for persons with diabetic gastroparesis.1,3 Initially, one should try the lowest effective dose of liquid metoclopramide, minimizing the risk of tardive dyskinesia/movement disorders. Erythromycin also can be effective but is more likely to lead to the development of tachyphylaxis with prolonged use. Tricyclic antidepressants may alleviate symptoms of nausea and vomiting but do not improve gastric emptying and may even exacerbate delayed gastric emptying.1,3
Empirical off-label medications may be given for symptomatic relief, including phenothiazines, antihistamines, 5-HT receptor agonists, and transdermal scopolamine, but evidence is lacking regarding overall effectiveness and safety.1 There is some evidence that acupuncture may improve emptying and symptom relief in some patients.
Q. What surgical management options are available for diabetic gastroparesis?
A. Gastric electrical stimulation may be effective for persons with diabetic gastroparesis and should be considered as a form of compassionate treatment in persons with refractory symptoms.1,3 Gastrotomy (venting), jejunostomy, intrapyloric injection of botulinum toxin, or completion gastrectomy may be considered for persons who have not responded to other medical or surgical treatment.1,3 There have been some case reports of benefit from endoscopic pyloromyotomy.3,5 However, surgical interventions are not proven to be effective in all cases.1
Kim A. Carmichael, MD, is a professor of medicine in the Department of Medicine, Division of Endocrinology, Metabolism and Lipid Research, at Washington University School of Medicine in St Louis, Missouri. He discloses that he is on the speakers bureau for Janssen, which may be relevant to the content of this article.
References:
- Camilleri M, Parkman HP, Shaft MA, Abell TL, Gerson L. Clinical guideline: management of gastroparesis. Am J Gastroenterol. 2013;108(1):18-37.
- Shin AS, Camilleri M. Diagnostic assessment of diabetic gastroparesis. Diabetes. 2013;62(8):2667-2673.
- Tack J, Carbone F, Rotondo A. Gastroparesis. Curr Opin Gastroenterol. 2015;31(6):499-505.
- Phillips LK, Deane AM, Jones KL, Rayner CK, Horowitz M. Gastric emptying and glycaemia in health and diabetes mellitus. Nat Rev Endocrinol. 2015;11:112-28.