Sunday, May 15, 2016

Gastroparesis in Diabetics

Gastroparesis, also called delayed gastric emptying, is a disorder in which the stomach takes too long to empty its contents. It often occurs in people with type 1 diabetes or type 2 diabetes.

Gastroparesis happens when nerves to the stomach are damaged or stop working. The vagus nerve controls the movement of food through the digestive tract. If the vagus nerve is damaged, the muscles of the stomach and intestines do not work normally, and the movement of food is slowed or stopped.
Diabetes can damage the vagus nerve if blood glucose levels remain high over a long period of time. High blood glucose causes chemical changes in nerves and damages the blood vessels that carry oxygen and nutrients to the nerves.

Signs and Symptoms of Gastroparesis

  • heartburn
  • nausea
  • vomiting of undigested food
  • an early feeling of fullness when eating
  • weight loss
  • abdominal bloating
  • erratic blood glucose levels
  • lack of appetite
  • gastroesophageal reflux
  • spasms of the stomach wall
These symptoms may be mild or severe, depending on the person.

Complications of Gastroparesis

If food lingers too long in the stomach, it can cause problems like bacterial overgrowth from the fermentation of food. Also, the food can harden into solid masses called bezoars that may cause nausea, vomiting, and obstruction in the stomach. Bezoars can be dangerous if they block the passage of food into the small intestine.
Gastroparesis can make diabetes worse by adding to the difficulty of controlling blood glucose. When food that has been delayed in the stomach finally enters the small intestine and is absorbed, blood glucose levels rise. Since gastroparesis makes stomach emptying unpredictable, a person's blood glucose levels can be erratic and difficult to control.

Major Causes of Gastroparesis

Gastroparesis is most often caused by
  • diabetes
  • postviral syndromes
  • anorexia nervosa
  • surgery on the stomach or vagus nerve
  • medications, particularly anticholinergics and narcotics (drugs that slow contractions in the intestine)
  • gastroesophageal reflux disease (rarely)
  • smooth muscle disorders such as amyloidosis and scleroderma
  • nervous system diseases, including abdominal migraine and Parkinson's disease
  • metabolic disorders, including hypothyroidism

Diagnosis of Gastroparesis

The diagnosis of gastroparesis is confirmed through one or more of the following tests.
  • Barium x ray. After fasting for 12 hours, you will drink a thick liquid called barium, which coats the inside of the stomach, making it show up on the x ray. Normally, the stomach will be empty of all food after 12 hours of fasting. If the x ray shows food in the stomach, gastroparesis is likely. If the x ray shows an empty stomach but the doctor still suspects that you have delayed emptying, you may need to repeat the test another day. On any one day, a person with gastroparesis may digest a meal normally, giving a falsely normal test result. If you have diabetes, your doctor may have special instructions about fasting.
  • Barium beefsteak meal. You will eat a meal that contains barium, thus allowing the radiologist to watch your stomach as it digests the meal. The amount of time it takes for the barium meal to be digested and leave the stomach gives the doctor an idea of how well the stomach is working. This test can help detect emptying problems that do not show up on the liquid barium x ray. In fact, people who have diabetes-related gastroparesis often digest fluid normally, so the barium beefsteak meal can be more useful.
  • Radioisotope gastric-emptying scan. You will eat food that contains a radioisotope, a slightly radioactive substance that will show up on the scan. The dose of radiation from the radioisotope is small and not dangerous. After eating, you will lie under a machine that detects the radioisotope and shows an image of the food in the stomach and how quickly it leaves the stomach. Gastroparesis is diagnosed if more than half of the food remains in the stomach after 2 hours.
  • Gastric manometry. This test measures electrical and muscular activity in the stomach. The doctor passes a thin tube down the throat into the stomach. The tube contains a wire that takes measurements of the stomach's electrical and muscular activity as it digests liquids and solid food. The measurements show how the stomach is working and whether there is any delay in digestion.
  • Blood tests. The doctor may also order laboratory tests to check blood counts and to measure chemical and electrolyte levels.
To rule out causes of gastroparesis other than diabetes, the doctor may do an upper endoscopy or an ultrasound.
  • Upper endoscopy. After giving you a sedative, the doctor passes a long, thin tube called an endoscope through the mouth and gently 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.
  • Ultrasound. To rule out gallbladder disease or pancreatitis as a source of the problem, you may have an ultrasound test, which uses harmless sound waves to outline and define the shape of the gallbladder and pancreas.
Treatment
The primary treatment goal for gastroparesis related to diabetes is to regain control of blood glucose levels. The best treatment is to use a superior nutritional wellness protocol such as the Super Meal Model Diet for Diabetics.
Changing your eating habits can help control gastroparesis. Your doctor or dietitian may prescribe six small meals a day instead of three large ones. If less food enters the stomach each time you eat, it may not become overly full. In more severe cases, a liquid or pureed diet may be prescribed. Liquid meals provide all the nutrients found in solid foods, but can pass through the stomach more easily and quickly. In that case, raw juicing, smoothies, and wholefood supplements can help tremendously to obtain the necessary nutrients.  Consequently, we recommend the Death to Diabetes ebook and the  Power of Juicing ebook.

Your doctor may recommend that you avoid high-fat and high-fiber foods. Fat naturally slows digestion—a problem you do not need if you have gastroparesis—and fiber is difficult to digest. Some high-fiber foods like oranges and broccoli contain material that cannot be digested. Avoid these foods because the indigestible part will remain in the stomach too long and possibly form bezoars.

To summarize:
  • Eat smaller meals more frequently.
  • Eat low-fiber forms of high-fiber foods, such as well-cooked fruits and vegetables rather than raw fruits and vegetables.
  • Choose mostly low-fat foods, but if you can tolerate them, add small servings of fatty foods to your diet.
  • Avoid fibrous fruits and vegetables, such as oranges and broccoli, that may cause bezoars.
  • If liquids are easier for you to ingest, try soups and pureed foods.
  • Drink water throughout each meal.
  • Try gentle exercise after you eat, such as going for a walk.
Some people with gastroparesis may be unable to tolerate any food or liquids. In these situations, doctors may recommend a feeding tube (jejunostomy tube) be placed in the small intestine.
Feeding tubes can be passed through your nose or mouth or directly into your small intestine through your skin. The tube is usually temporary and is only used when gastroparesis is severe or when blood sugar levels can't be controlled by any other method.
If treatment doesn't help control your nausea, vomiting or malnutrition, you may consider gastroparesis surgery. During surgery, the lower part of the stomach may be stapled or bypassed to help improve stomach emptying.

Gastric electrical stimulation (GES): Another possible treatment for more serious cases may require a gastric pacemaker, which uses an electric current to provide electrical gastric stimulation  to cause stomach contractions. Working much like a heart pacemaker, this stomach pacemaker, consisting of a tiny generator and two electrodes, is placed in a pocket that surgeons create on the stomach's outer edge. Stomach pacemakers have been shown to improve stomach emptying and reduce nausea and vomiting in some people with gastroparesis, but more studies are needed.

Here is a link to an external website that provides a more structured approach to eating smaller meals for treating gastroparesis:
http://www.gicare.com/diets/Gastroparesis.aspxOther treatments include insulin, oral medications, and, in severe cases, feeding tubes and intravenous feeding.
It is important to note that in most cases treatment does not cure gastroparesis -- it is usually a chronic condition. Treatment helps you manage the condition so that you can be as healthy and comfortable as possible.
Insulin for blood glucose control
If you have gastroparesis and you are on insulin, your food is being absorbed more slowly and at unpredictable times. To better control blood glucose, levels your doctor may recommend that you:
  • 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.

Medication for Gastroparesis

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 drug stimulates stomach muscle contractions to help empty food. It also helps reduce nausea and vomiting. Metoclopramide is taken 20 to 30 minutes before meals and at bedtime. Side effects of this drug are fatigue, sleepiness, and sometimes depression, anxiety, and problems with physical movement.
  • Erythromycin. This antibiotic also improves stomach emptying. It works by increasing the contractions that move food through the stomach. Side effects are nausea, vomiting, and abdominal cramps.
  • Domperidone. The Food and Drug Administration is reviewing domperidone, which has been used elsewhere in the world to treat gastroparesis. It is a promotility agent like metoclopramide. Domperidone also helps with nausea.
  • Other medications. Other medications may be used to treat symptoms and problems related to gastroparesis. For example, an antiemetic can help with nausea and vomiting. Antibiotics will clear up a bacterial infection. If you have a bezoar, the doctor may use an endoscope to inject medication that will dissolve it.

Hope Through Research on Gastroparesis

NIDDK's Division of Digestive Diseases and Nutrition supports basic and clinical research into gastrointestinal motility disorders, including gastroparesis. Among other areas, researchers are studying whether experimental medications can relieve or reduce symptoms of gastroparesis, such as bloating, abdominal pain, nausea, and vomiting, or shorten the time needed by the stomach to empty its contents following a standard meal.

Points to Remember about Gastroparesis

  • Control your blood glucose levels to prevent gastroparesis.
  • Gastroparesis may occur in people with type 1 diabetes or type 2 diabetes.
  • Gastroparesis is the result of damage to the vagus nerve, which controls the movement of food through the digestive system. Instead of the food moving through the digestive tract normally, it is retained in the stomach.
  • The vagus nerve becomes damaged after years of poor blood glucose control, resulting in gastroparesis. In turn, gastroparesis contributes to poor blood glucose control.
  • Symptoms of gastroparesis include early fullness, nausea, vomiting, and weight loss.
  • Gastroparesis is diagnosed through tests such as x rays, manometry, and scanning.
  • Treatments include changes in when and what you eat, changes in insulin type and timing of injections, oral medications, a jejunostomy, parenteral nutrition, gastric pacemakers, or botulinum toxin.
  • Change your diet to an alkaline-based diet such as  the Super Meal Model Diet for Diabetics
  • Eat more nutritious liquid meals that can pass through the stomach more easily and quickly, i.e. raw juices, smoothies. Get the Power of Juicing ebook.
References (for Gastroparesis):
  1. ^ "Spotlight on gastroparesis," unauthored article, Balance (magazine of Diabetes UK, no. 246, May-June 2012, p. 43.
  2. ^ "Gastroparesis - Your Guide to Gastroparesis - Causes of Gastroparesis". Heartburn.about.com. Retrieved 2012-02-10.
  3. ^ "Gastroparesis: Causes". MayoClinic.com. 2012-01-04. Retrieved 2012-10-09.
  4. ^ "Epocrates article, registration required". Online.epocrates.com. Retrieved 2012-10-09.
  5. a b "Summary for Oley Foundation by R. W. McCallum, MD". Oley.org. Retrieved 2012-10-09.
  6. ^ "Gastroparesis: Symptoms". MayoClinic.com. 2012-01-04. Retrieved 2012-10-09.
  7. ^ Mirtazapine for Severe Gastroparesis Unresponsive to Conventional Prokinetic Treatment
  8. http://www.aetna.com/cpb/medical/data/600_699/0678.html
  9. G-PACT Gastroparesis Patient Association
  10. Overview from NIDDK National Institute of Diabetes, Digestive, and Kidney Diseases at NIH
  11. Overview at Mayo Clinic
  12. Overview at University of Chicago Hospitals
  13. Patient Perspective at the icarecafe

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