Diabetic Gastroparesis

If you have diabetes, you may have noticed that your digestion isn’t quite what it used to be. The connection isn’t obvious, but diabetes can damage the nervous system in ways that show up in the form of stomach or bowel problems. It’s sometimes referred to as diabetic gastroparesis.

What is gastroparesis?

 In gastroparesis, also called delayed gastric emptying, the stomach takes too long to empty its contents. Here’s how it works.

The autonomic nervous system—the part of the nervous system that “automatically” regulates our internal organs while we go about our lives —controls the movement of food through the digestive tract. Normally, the vagus nerve, which controls the muscles of the stomach, tells the muscles to contract after a meal or snack to break up food and move it along to the small intestine. But if the vagus nerve is damaged, the muscles of the stomach don’t work normally, and the movement of food slows or even grinds to a halt.

Diabetes is the most common known cause of gastroparesis. Type 1 and type 2 diabetes can damage the vagus nerve if blood glucose levels stay high for too long. How? High blood glucose causes chemical changes in nerves and damages the blood vessels that bring them much-needed oxygen and nutrients.

While there’s no cure for gastroparesis, treatment can help manage the condition.

What are the signs of gastroparesis?

Signs and symptoms may be mild or severe and can include:

• heartburn
• nausea
• vomiting of undigested food
• an early feeling of fullness when eating
• weight loss
• abdominal bloating
• erratic blood glucose levels
• lack of appetite
• acid reflux
• spasms of the stomach wall
• erratic bowel movements

Symptoms might be worse after eating greasy or rich foods or large quantities of high-fiber foods (such as raw fruits and vegetables) or drinking carbonated drinks or high-fat beverages.

In some people, symptoms occur frequently; in others, they happen only occasionally. They may also vary in intensity over time.

Complications of gastroparesis

Food in the stomach can harden and cause nausea, vomiting, and obstruction.

Gastroparesis can also cause malnutrition due to poor absorption of nutrients. Persistent vomiting due to extreme gastroparesis can cause severe dehydration. When gastroparesis leads to severe nausea, vomiting, and dehydration, IV fluids may be needed.

The condition can make diabetes worse by making it harder to control blood glucose levels. What happens is this: When food that has been delayed in the stomach finally enters the small intestine and is absorbed, blood glucose rises. Since stomach emptying is unpredictable, the rise in blood glucose is, too.

How is gastroparesis diagnosed?

 A doctor may use one or more of the following tests to confirm a diagnosis of gastroparesis:

• Upper endoscopy.After giving you a sedative, the doctor passes a long, thin tube called an endoscope through the mouth and guides it down the esophagus into the stomach. Through the endoscope, the doctor can look at the lining of the stomach to check for any abnormalities.
• Upper GI series.After fasting for 8 hours, you will drink a chalky liquid called barium, which coats the inside of the stomach, making signs of gastroparesis show up more clearly on x rays. Gastroparesis is likely if the x ray shows food in the stomach after fasting. If you have diabetes, your doctor may have special instructions about fasting.
• To rule out gallbladder disease or pancreatitis as a source of the problem, you may have an ultrasound test, which uses a device to bounce sound waves off the gallbladder and pancreas in order to create an image of them.
• Gastric emptying scintigraphy.The test, performed in a radiology center or hospital, involves eating a bland meal (such as eggs or an egg substitute) that contains a small, harmless amount of radioactive material. An external camera scans the abdomen to show where the radioactive material is located. The radiologist can then measure the rate of gastric emptying at one, two, three and four hours after the meal. If more than ten percent of the meal is still in the stomach at four hours, gastroparesis is confirmed.
  In this test, available at specialized outpatient centers, you swallow a small electronic device in capsule form. As it moves through the digestive tract, it sends information to a cell-phone-sized receiver worn around your waist or neck. The information provides a detailed record of how quickly food travels through each part of the digestive tract.
• Gastric emptying breath test.This test is yet another way for a health care provider to see how fast the stomach empties. You eat a meal that includes Spirulina (a nutritional supplement) enriched with a type of carbon that can be measured in the breath. Breath samples are taken over a period of several hours to measure the amount of carbon-13 in the breath.

How Is gastroparesis treated?

The primary treatment goals for gastroparesis in people with diabetes are to improve gastric emptying and regain control of blood glucose levels. Treatments include insulin, oral medications, dietary changes, and, in severe cases, a feeding tube or intravenous feeding.

Insulin regimen changes

To control blood glucose if you have gastroparesis and diabetes, you may need to:

• take insulin more often
• take your insulin after you eat instead of before
• check your blood glucose levels frequently after you eat and administer insulin whenever necessary

Your doctor will give you specific instructions based on your particular needs.

Diet and nutrition

Changing your eating habits can sometimes help control the severity of gastroparesis symptoms. A health care provider may suggest eating six small meals a day instead of three large ones. Chewing food well, drinking noncarbonated liquids with a meal, and walking or sitting for two hours after a meal instead of lying down may help with stomach emptying.

A health care provider may also recommend avoiding certain foods. Some foods, such as oranges and broccoli, contain fibrous parts that don’t digest well. People with gastroparesis should avoid eating large portions of these foods.

When a person has severe symptoms, a liquid or puréed diet may be prescribed. Since liquids tend to empty more quickly from the stomach, some people find a puréed diet improves symptom more. Puréed fresh or cooked fruits and vegetables can be incorporated into shakes and soups. A dietitian can help plan meals that minimize symptoms and ensure proper nutrition.

Medication

Several drugs are used to treat gastroparesis. Your doctor may try different drugs or combinations of drugs to find the most effective treatment.

• Metoclopramide (Reglan).This medication stimulates stomach muscle contractions. It also helps reduce nausea and vomiting. It’s taken twenty to thirty minutes before meals and at bedtime. Possible side effects include fatigue, sleepiness, and depression. Currently, it’s the only drug approved by the FDA for treating gastroparesis. However, the FDA has given it a black box warning due to rare reports of it causing an irreversible neurologic side effect called tardive dyskinesia, a disorder that affects movement.
• This antibiotic, prescribed at low doses, may improve stomach emptying by increasing stomach contractions. Side effects may include nausea, vomiting, and abdominal cramps.
• Other medications.Other medications may be used to treat certain problems related to gastroparesis. For example, an antiemetic can help with nausea and vomiting.

Gastric Electrical Stimulation

This treatment alternative may be effective for some people whose nausea and vomiting don’t improve with dietary changes or medications. A battery-operated device called a gastric neurostimulator is a surgically implanted. It sends mild electrical pulses to the stomach muscles to help control nausea and vomiting. Once it’s implanted, the settings can be adjusted to best control symptoms.

Botulinum Toxin (Botox)

Botulinum toxin, or Botox, is a nerve blocking agent. To treat you with Botox, the doctor will first pass an endoscope into your stomach, then inject the Botox into your pylorus, the opening from the stomach into the duodenum (the first part of the small intestine). Botox is supposed to help keep the pylorus open for longer periods of time and improve symptoms of gastroparesis.

Although some initial research trials showed modest improvement in gastroparesis symptoms and the rate of gastric emptying following the injections, other studies have failed to show the same degree of effectiveness.

Jejunostomy

If medications and dietary changes don’t work and the person is losing weight or requires frequent hospitalization for dehydration, a health care provider may recommend surgically placing a feeding tube through the abdominal wall into a part of the small intestine called the jejunum. The feeding tube bypasses the stomach and delivers a special liquid food directly into the jejunum. A jejunostomy is used only when gastroparesis is extremely severe.

Parenteral Nutrition

When gastroparesis is so severe that dietary measures and other treatments are not helping, a health care provider may recommend parenteral nutrition, an IV liquid food mixture supplied through a special tube in the chest. This approach is usually a temporary measure to get through a difficult period of gastroparesis

Adapted from the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.

Updated March 2017.