Updated: 5/22/2019

Diabetic Gastroparesis

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Snapshot
  • A 56-year-old woman presents to the emergency clinic for recurrent nausea and vomiting for the past 3 weeks. On average, these episodes occur after food intake, which the patient reports, has significantly decreased in amount as she now feels full quickly. Her past medical history is significant for poorly-controlled diabetes for the past 10 years. A physical examination demonstrates epigastric distention and tenderness with no peritoneal signs.
Introduction
  • Clinical definition
    • syndrome of delayed gastric emptying in the absence of a mechanical obstruction and the presence of cardinal symptoms (e.g., nausea) secondary to diabetes mellitus (DM)
    • other causes of gastroparesis includes
      • idiopathic
      • viral infection (e.g., cytomegalovirus)
      • medications (e.g., tricyclic antidepressants)
      • postsurgical
  • Epidemiology
    • demographics
      • DM is the most common systemic disease associated with gastroparesis
      • symptoms of gastroparesis are reported in 11-18% of patients with DM
    • risk factors
      • typically occurs in patients who have had DM for over 5 years
      • chronic hyperglycemia (blood glucose > 200mg/dL)   
  • Pathogenesis
    • abnormalities of antral motor function and coordination and postprandial proximal gastric accommodation and contraction
      • primarily due to autonomic dysfunction and/or abnormal intrinsic nervous system (e.g., interstitial cells of Cajal, the pacemaker of the gut)
      • other proposed contributing factors 
        • hyperglycemia
        • vagal dysfunction
        • loss of neural nitric oxide synthase (nNOS) expression
        • oxidative stress
Presentation
  • Symptoms 
    • nausea 
    • vomiting
    • abdominal pain  
    • early satiety  
    • postprandial fullness
    • bloating
    • weight loss if severe
  • Physical exam
    • epigastric distension/tenderness
    • succession splash
    • other signs of autonomic dysfunction (e.g., orthostatic hypotension)
Studies
  • Diagnostic testing
    • diagnostic approach
      • diagnosis is based on clinical presentation and confirmed with gastric emptying studies
    • imaging
      • upper gastrointestinal endoscopy
        • initial test performed to exclude mechanical obstruction
        • alternative options include computed tomographic (CT) or magnetic resonance (MR) enterography
      • scintigraphic gastric emptying
        • most cost effective and widely available technique to confirm delayed gastric emptying
        • usually evaluates the gastric emptying of solids
    • studies
      • laboratory studies
        • HbA1c for assessment of glycemic control
        • other tests such as hemoglobin, TSH, ANA, and albumin for evaluation of other etiologies
Differential
  • Psychiatric disease 
    • distinguishing factors
      • patients may have a history of psychiatric disease (e.g., bulimia)
      • some patients may have a normal scintigraphic emptying study
  • Cyclic vomiting syndrome 
    • distinguishing factors
      • clinical presentation of intense vomiting episodes separated by symptom-free periods
      • history of cannabinoid use
Treatment
  • First-line
    • dietary modification (for patients with mild disease)
      • avoid foods that are fatty, acidic, spicy, and roughage-based
      • avoid alcohol and smoking
    • optimization of glycemic control
      • acute hyperglycemia has been demonstrated to slow gastric emptying
    • if continued symptoms, pharmacologic therapy with prokinetic and antiemetics
      • metoclopramide is the first-line prokinetic  
      • second-line prokinetics includes domperidone, erythromycin, and cisapride
      • antiemetics include diphenhydramine, ondansetron, and prochlorperazine
  • Second-line
    • indicated in patients with refractory symptoms despite first-line therapy
    • endoscopic gastrostomy tube decompression and jejunal feeding tube
    • surgical treatments
    • tricyclic antidepressants (low-dose nortriptyline)
Complications
  • Electrolyte imbalance
  • Malnutrition
 

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