Type 2 diabetes – Gastroparesis

Diabetic gastroparesis -Delayed gastric emptying with associated upper GI symptoms in absence of any mechanical obstruction is described by the term diabetic gastroparesis ( previously also known by the term Gastroparesis diabeticorum ) Associated symptoms include
○ post prandial fullness ○ nausea ○ vomiting ( often undigested food )
○ anorexia ○ weight loss / gain ○ can happen with or without abdominal pain NICE recommends to consider DGp in those with type 2 diabetes who have erratic blood glucose control or unexplained gastric bloating or vomiting ( taking into account other possible alternative diagnoses )

symptoms associated with DGp can be seen in 
5 % to 12 % of patients with diabetes more common in type 1 diabetes and usually after a duration of 10 yrs incretin based therapy increases the risk of DGp in type 2 diabetes patients.

consistently raised glucose levels cause neuronal damage dysfunction in the coordination and function of the autonomic NS , neurons and specialised pacemaker cells of the stomach and intestine and smooth muscles of the GI tract effects of raised post prandial glucose levels.

other conditions which need to be excluded include gastric outlet obstruction , functional dyspepsia , chronic pancreatitis , biliary colic tests which can be considered to establish the diagnosis/ rule out other conditions include
○ upper GI endoscopy ( r/o mechanical obstruction and peptic ulcer disease )
○ CT scan or IV contrast / small bowel F/U
○ scintigraphy ( considered gold standard )
○ breath test

Once DGp develops it can lead to
 poor glycemic control 
( wide glycemic fluctuations ) poor nutrition ( malnutrition ) and dehydration 
( frequent hospitalizations ) poor QoL risk aspiration pneumonia DgP diagnosis and management is challenging 
( remains undetected ) and refractory to therapy.

NICE guideline -Those with type 2 diabetes who suffer with vomiting due
 to DGp advise that
 no strong evidence that any available antiemetic treatment is effective some people have had benefit with domperidone , erythromycin or metoclopramide strongest evidence is for domperidone -take into account
○ safety profile ○ cardiac risk ○ potential interactions.

To treat vomiting consider
 alternating the use of erythromycin BNF dose is 250 mg to 500 mg TDS 
( off label use 2015 ) and metoclopramide domperidone only in exceptional circumstances

To treat vomiting consider
 alternating the use of erythromycin BNF dose is 250 mg to 500 mg TDS 
( off label use 2015 ) and metoclopramide domperidone only in exceptional circumstances.

Referral diagnosis is in doubt or differential diagnosis is in doubt or ( seek advice from specialist team ) persistent severe vomiting / symptoms difficult to manage in primary care.

REFERENCES

1. Krishnasamy, Sathya, and Thomas L Abell. “Diabetic Gastroparesis: Principles and Current Trends in Management.” Diabetes therapy : research, treatment and education of diabetes and related disorders vol. 9,Suppl 1 (2018): 1-42. doi:10.1007/s13300-018-0454-9
2. Aswath GS, Foris LA, Ashwath AK, et al. Diabetic Gastroparesis. [Updated 2021 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430794/
3. Type 2 diabetes in adults: management NG 28 *Type 2 diabetes in adults: management (nice.org.uk)