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					   Fact sheet 47
                                                        Up to 50 per cent of people with

  Diabetes                                              diabetes may have some degree of
                                                        gastroparesis. Jo Brodie takes a closer

  in practice                                           look at the condition and what it
                                                        means for diabetes management

The transit and digestion of food through the               Autonomic neuropathy and gastroparesis is
gastrointestinal tract depends on a co-ordinated        common in both Type 1 and Type 2 diabetes. From
effort between nerves and muscles. The functioning      a few, small studies it has been estimated that
of these nerves and muscles, as well as the blood       around 30 to 50 per cent of people with diabetes
vessels that supply them, is susceptible to acute and   will have some degree of gastroparesis, although
long-term rises in blood glucose and every part of      the condition is likely to be (initially) asymptomatic
the tract (from the swallowing reflex to expulsion      in most individuals. A recent review suggested that
of waste matter) can be affected by raised glucose      symptoms attributable to gastroparesis are report-
levels. This factsheet looks at the effects of hyper-   ed by up to 12 per cent of people with diabetes and
glycaemia on the actions of the stomach – and how       such symptoms are often likely to be attributed to
such actions can have a knock-on effect on blood        general problems relating to diabetes.
glucose levels.                                             Gastroparesis also occurs in people without
                                                        diabetes and can result from medications,
What is gastroparesis?                                  viral infections, other medical conditions (eg
Gastroparesis (literally ‘stomach paralysis’) or        Parkinsonism, thyroid conditions) and, more rarely,
‘delayed gastric emptying’ is a syndrome where, in      can also occur after surgery.
the absence of any mechanical obstruction, the
stomach takes too long to pass partially digested       What are the implications for diabetic control
food to the intestine for further digestion and         If the stomach fails to work as it should, several
absorption.                                             things can happen. Irregular stomach emptying
    The vagus nerve, which controls the gastro-         makes it harder to predict the timing of the post-
intestinal contortions required for digestion of        meal rise in blood glucose, following absorption in
food, and its propulsion towards the intestine, can     the intestines, and thus harder to match the
be damaged by years of raised blood glucose levels      required insulin dose. This means that there can be
resulting in autonomic neuropathy and a stomach         a timing mismatch between any insulin injected
unable to fulfil its proper function.                   and the arrival of glucose in the bloodstream
    In the absence of neuropathy even acutely           leading to lows (when the insulin arrives in the
raised blood glucose levels can disturb gastro-         bloodstream before the meal has been absorbed)
intestinal functioning; artificially raising healthy    followed by highs (as glucose is absorbed later into
volunteers’ blood glucose levels from 7mmol/L to        the bloodstream, by which time the insulin has
15mmol/L has been shown to slow the rate of             passed its effective peak).
gastric emptying. Gastroparesis can therefore be            Highly erratic glucose levels are probably the
the result of both direct and indirect effects of       most common ‘symptom’ of gastroparesis and
raised blood glucose levels.                            screening for the syndrome may be worthwhile,
                                                        even in those who are otherwise asymptomatic for
Who develops gastroparesis?                             gastroparesis. This variability in glycaemic
People with diabetes who develop gastroparesis are      excursions, and in particular the hyperglycaemic
likely to have had diabetes for at least 10 years and   episodes, can worsen gastroparesis further.
may have other complications as well, such as               In addition to the close relationship between
neuropathy, retinopathy and nephropathy.                food digestion, absorption and blood glucose
   Fact sheet 47

  in practice
levels, the negative impact on the quality of life in    scintigraphy, in which the fasted patient eats a
people with gastrointestinal disturbances can be         ‘meal’ comprising differently radio-labelled solid
severe. If physical symptoms are more severe (see        and liquid foodstuffs in order to compare the rate
below) then this can be quite debilitating, and          of emptying of solids and liquids.
episodes of diarrhoea and constipation related
to diabetes can create havoc with normal life            What should the patient pathway be once
activities, for example eating out. Partially digested   gastroparesis has been identified?
food can remain in the stomach, resulting in             There are two aims in treating gastroparesis: to
bacterial overgrowth and occasionally to the             improve glycaemic control and to alleviate any
development of bezoars (solid masses) that can           symptoms; a combination of medication and
result in blockages and absorption of other              lifestyle changes can help. Since nicotine can
medications may also be impaired.                        worsen gastrointestinal problems, smoking
                                                         cessation advice should be given where
How to identify gastroparesis                            appropriate.
There may be no ‘red flags’ highlighting the                 Dietary changes might include having several
presence of gastroparesis or other autonomic             smaller meals (six to eight rather than the more
neuropathies as the early symptoms can be too            usual three) throughout the day and avoiding
subtle or absent, the only clue perhaps being            meals with a high fat or fibre content. Fibre-rich
erratic glucose control.                                 foods are normally recommended as part of a
   The prevalence of gastrointestinal symptoms is        healthy diet. However, despite their beneficial
higher in people with diabetes compared with the         effects in the intestines, their relative indigestibility
general population but a patient’s own concerns          can make such foods unsuitable for people
about any symptoms are not always volunteered            suffering from gastroparesis or other dysmotility
and may be seen as related to irritable bowel            syndromes.
syndrome rather than as a consequence of                     If the patient uses insulin the dose could be split
diabetes.                                                before and after the meal and injection into areas
   In addition to erratic blood glucose control, the     from which absorption is typically slower (eg thigh)
more obvious physical symptoms (which may be             may be helpful, as can use of an insulin pump,
absent in many people) include:                          which allows the mealtime bolus insulin to be
• Bloating, abdominal pain and early fullness after      spread over a longer time. In addition, normo-
  eating only a small amount of food.                    glycaemia improves gastric emptying rates.
• Heartburn and nausea, sometimes accompanied                The use of metoclopramide or domperidone,
  by vomiting. Vomiting can occur several hours          both of which have prokinetic (improving gastric
  after eating when the stomach is at its fullest        movement) and antiemetic (reducing nausea
  with undigested food and secretions and, because       symptoms) effects may be of benefit – though
  of a lack of digestion, the vomitus may be             metoclopramide should be used in the short term
  recognised as the recent meal.                         only. Where gastroparesis symptoms do not
• Gastro-oesophageal reflux.                             respond to antiemetic medications the intravenous
• Weight loss from poor absorption of food (rare).       use of the macrolide antibiotic (and motilin
                                                         receptor agonist) erythromycin might be consid-
What to do if you suspect it                             ered and, if successful, the drug can be offered as
There may be reversible causes of gastroparesis or       an oral suspension for subsequent home use.
gastrointestinal dysfunction, relating to other              An implantable gastroelectric stimulation device,
conditions (hypothyroidism), infections (gastric         Enterra (Medtronic), has been tried in a number of
candidiasis) or medications (eg calcium channel          patients worldwide and shown to have an effect on
blockers) and upper gastrointestinal endoscopy can       vomiting frequency but no significant effect on the
be performed to exclude any physical obstruction.        rate of gastric emptying. NICE guidelines currently
Positive diagnosis requires gastric emptying             restrict its use to specialist gastroenterology units.