What You Should Know About Diabetic Gastroparesis
Asymptomatic patients may present with bezoar formation, unexplained hypoglycemic reactions, erratic absorption of oral medications, esophageal reflux and, rarely, even gastric bacterial overgrowth or candidiasis. Common symptomatic complaints include early satiety, anorexia, post-prandial fullness, nausea, vomiting, epigastric discomfort or pain, bloating, belching, heartburn, halitosis and weight loss. Severe cases of DG, if left untreated, can lead to nausea, vomiting, dehydration, malnutrition and ketoacidosis. Pertinent Pointers For Managing The Condition Once you have confirmed the diagnosis of DG, management consists of dietary and lifestyle modifications, glucose control, pharmacologic therapy and consideration of alternate feeding routes. The goal of treatment is to provide GI symptom relief, prevent the progression of neuropathy and enhance the quality of life. Glycemic control is very important in these patients because hyperglycemia can decrease gastric mobility, resulting in delayed gastric emptying. Some patients are able to improve by emphasizing good glycemic control and small, regular, frequent meals. Although the mainstay of treatment continues to be the use of pharmacological agents, there is strong evidence supporting the management of DG symptoms with prokinetic agents. Gastrokinetics, such as raglan, motilium and propulsid, stimulate gastric motility and promote more physiologic contraction in the stomach, pylorus, duodenum and small bowel. When it comes to the acutely ill patient with intractable symptoms, employing a feeding tube may be most beneficial. Using a jejunostomy tube allows the nutrients to bypass the stomach altogether. This method of treatment is particularly useful when severe gastroparesis prevents nutrient and medication absorption into the bloodstream. One may use jejunostomy feeding temporarily when gastroparesis is severe or it can be used permanently. Parenteral nutrition, an alternative approach to the jejunostomy tube, is usually a temporary method that is only used in cases of severe gastroparesis. An Early Glimpse At New Treatments In The Works There is hope through research and new treatments. One of those treatments under investigation is a gastric neurostimulator (“pacemaker”) that has been developed to assist in management of gastroparesis. It is a battery-operated, electronic device that is surgically implanted and emits mild electrical pulses that stimulate stomach contractions so food is digested and moved from the stomach into the intestines. This electrical stimulation has also been found to help control the nausea and vomiting associated with gastroparesis. Another new treatment uses botulinum toxin to decrease the prolonged contractions of the pyloric sphincter between the stomach and the small intestine. The toxin is injected into the pyloric sphincter and has early promise for stimulating gastric emptying. Final Notes There are multiple complications and symptoms that may arise from delayed gastric emptying. When this is left untreated, it can substantially impair the patient’s quality of life. There is also some concern that DG may be correlated with an increase in mortality among patients with diabetes. It is also well accepted that the presence of DG is a strong indicator of other advanced diabetic complications (nephropathy, retinopathy, functional microvascular disease and peripheral neuropathy). DG is a late manifestation of autonomic neuropathy and is associated with a poor prognosis. It is important to note that, in most cases, treatment does not cure gastroparesis. This is usually a chronic condition, but regaining control of blood glucose levels through treatment can help patients manage the condition and enhance their quality of life. Dr. Jansma is a first-year resident within the Department of Orthopaedics, Podiatry Division at the University of Texas Health Science Center in San Antonio, Texas. Dr. Steinberg (shown at the right) is an Assistant Professor within the Department of Orthopaedics, Podiatry Division at the University of Texas Health Science Center in San Antonio, Texas.