Diabetic Gastroparesis
Diabetic Gastroparesis
Abstract & Commentary
By Malcolm Robinson, MD, FACP, FACG, Emeritus Clinical Professor of Medicine, University of Oklahoma College of Medicine, Oklahoma City. Dr. Robinson reports no financial relationship to this field of study.
Synopsis: Diabetic gastroparesis, delayed gastric emptying associated with diabetes mellitus, may occur in more than 10% of diabetic patients and can be severely symptomatic and refractory to management.
Source: Camilleri, M. The New England Journal of Medicine. 2007;356:820-829.
Gastroparesis is defined as delayed gastric emptying in the absence of any mechanical gastric outlet obstruction. Although potentially associated with a number of medical conditions other than diabetes mellitus (DM), diabetes is probably the most common comorbidity. Most diabetics with gastroparesis have had DM for 10 years or more, and they often have other neuropathy, nephropathy, and diabetic ophthalmic manifestations. Oddly enough, chronic diabetic gastroparesis is often nonprogressive and does not seem to alter mortality. Common symptoms of gastroparesis include nausea, vomiting, and early satiety. Daily vomiting is unusual unless gastroparesis is extremely severe.
The physiology of the normal stomach involves rapid emptying of non-caloric liquids, slower emptying of progressively more nutrient rich liquids, and much slower gastric emptying of churned and triturated solids. Gastroparesis in DM seems largely related to vagal neuropathy. Also, even in the presence of normal vagal function, hyperglycemia can lead to slowed gastric emptying. Differential diagnosis of gastroparesis includes peptic ulcer disease (including NSAID-related), malignant gastric obstruction, and the functional rumination syndrome (chronic effortless regurgitation of food). Physical examination of patients with diabetic gastroparesis tends to reveal peripheral and autonomic neuropathy (eg, pupils reactive to accommodation and not to light), and there may be an abdominal succussion splash. Barium studies or endoscopy will demonstrate food in the stomach after 12 hours of fasting. Scintigraphic measurement of gastric emptying is the gold standard for diagnosis of gastroparesis. Treatment should begin with an attempt to regulate blood sugar levels. Physicians should try to eliminate medications likely to exacerbate poor gastric function such as calcium channel blockers, anticholinergic drugs of all sorts, and clonidine. Prokinetic agents that may help in the management of diabetic gastroparesis include metoclopramide, cisapride, domperidone, and erythromycin. Nonspecific antiemetics may help relieve symptoms, and it is suggested that inexpensive dimenhydrinate and meclizine should be tried first. Phenothiazines may be useful. 5-HT3 antagonists have not been formally studied but may be helpful. If pain is present, low dose antidepressants or pregabalin (a drug approved for diabetic neuropathic pain) might help. If severe weight loss is present, enteral nutrition can be considered. Gastrostomy or jejunostomy may occasionally be warranted. Some patients have received laparoscopically placed electrodes designed to provide continuous gastric electrical stimulation. Although gastric electrode stimulation doesn't seem to alter gastric emptying, gastroparetic symptoms may be partially relieved.
Commentary
Diabetic gastroparesis can be tremendously disabling, and many of these patients seem not to respond to any intervention. Dr. Camilleri, a world expert in this area, recommends endoscopy to rule out obstruction, confirmation of diagnosis by gastric emptying studies using scintigraphy, and step-up therapy beginning with metoclopramide and antiemetics. If all else fails, he believe that successful nasojejunal feeding should precede endoscopic jejunostomy. Although it is hard to argue with Dr. Camilleri's expertise and experience, I would recommend that metoclopramide should never be initiated without informed consent since this drug may lead to permanent tardive dyskinesia (and lawsuits). It is difficult to get access to cisapride in the United States although it remains available on a compassionate use basis here and is still sold elsewhere (eg, Mexico). Domperidone, potentially less noxious than metoclopramide, can be obtained in a number of countries including Canada. Dr. Richard McCallum and his colleagues in Kansas City have considerable experience with the Medtronic gastric electrode stimulation devices.1
Reference
1. Lin Z, et al. Neurogastroenterol Motil. 2006;18:18-27.
Diabetic gastroparesis, delayed gastric emptying associated with diabetes mellitus, may occur in more than 10% of diabetic patients and can be severely symptomatic and refractory to management.Subscribe Now for Access
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