Diabetic Gastroparesis

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Key points

  • Gastroparesis is delayed gastric emptying in the absence of obstruction, a complication that affects patients with type 2 as well as type 1 diabetes mellitus.

  • Symptoms associated with gastroparesis are nonspecific, and the diagnoses should be confirmed with gastric emptying tests.

  • Patients are often overweight and have nutritional deficiencies.

  • Obstructive gastroparesis, a subset of gastroparesis, is caused by pyloric dysfunction, and botulinum toxin A injections may be helpful.

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Epidemiology

A recent update reported that there are more than 36 million individuals with diabetes in North America and the Caribbean6 and most are cases of T2DM. The estimates of prevalence of gastroparesis in T1DM vary widely. Although in tertiary centers, up to 40% of patients with T1DM have gastroparesis,7 surveys in Olmsted County, Minnesota, indicated a prevalence of 5%.8

Similarly, in specialized centers, 10% to 30% of patients with T2DM have gastroparesis9; in Olmsted County, the prevalence was 1%.10

Normal postprandial gastric neuromuscular activity

The normal stomach performs a series of complex neuromuscular activities in response to the ingestion of solid foods.16 First, the fundus relaxes to accommodate the volume of ingested food (Fig. 1). Normal fundic relaxation requires an intact vagus nerve and is mediated by enteric neurons containing nitric oxide. The relaxation of the fundus allows food to be accommodated without excess stretch on the fundic walls.

Second, the corpus and antrum produce recurrent peristaltic waves that mix or

Gastric Neuropathy and Cajalopathy in Diabetic Gastroparesis

Full-thickness biopsies of the gastric corpus from patients with T1DM and T2DM and gastroparesis indicate that the disease is primarily a disease of gastric enteric neurons and ICCs.11, 12 We know that ICCs are depleted (<5/hpf compared with controls) in the diabetic gastroparesis stomach.11, 17 Gastric enteric neurons are decreased in numbers of cell bodies and processes are truncated. These neurons are surrounded by an immune infiltrate composed primarily of type 2 macrophages, suggesting a

Solid-Phase Gastric Emptying Test

Tests for gastroparesis and gastric dysrhythmias are nuclear medicine scintigraphy, wireless capsule endoscopy, and electrogastrography (EGG). These tests should be performed after upper endoscopy to rule out mechanical obstruction, which produces symptoms similar to gastroparesis. The most standardized test for gastric emptying is the technetium-labeled low-fat egg albumin-based meal.38, 39 The patient must stop prokinetic agents 7 days before the test, fast after midnight, and blood glucose

Acute dietary management of exacerbation of symptoms associated with gastroparesis

Patients who have frequent vomiting episodes that may lead to dehydration are coached to sip small volumes (Step 1 of Table 2; eg, 56.6 g [2 oz] over 30–60 minutes every hour) of electrolyte-containing liquids and bouillonlike soup broths throughout the day; this may be accomplished with commercially available sports drinks. The purpose is to restore hydration with salt and water. Nausea and vomiting often improve with hydration, and the patient may then advance to steps 2 and 3, as outlined in

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  • Cited by (0)

    Disclosures: 3 CPM Company, Shareholder; GlaxoSmithKline, Consultant (K.L. Koch, MD); The author has nothing to disclose (J. Calles-Escandón, MD).

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