Diabetic GastroparesisEvan M. Klass, MD, FACP

February 16, 2017

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Scope of the problem

• The disorder can affect any part of the GI tract• Although 10-20% of the general population suffer from

functional GI disorders, patients with Type 1 and Type 2 DM have more sx

• And the worse the sx the worse the associated Diabetes control• Patients with Type 1 are more likely to have gastroparesis• GI function tests are not always definitive

• Gastric emptying studies do not correlate with sx of nausea and vomiting

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Pathophysiology

• A manifestation of autonomic neuropathy- others of which include orthostatic hypotension, abnormal sweating

• Generally occurs following other microvascular complications• Disordered gastric or bowel contraction related to loss of

neuronal mass- denervation

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Clinical presentation

• Early satiety• Prolonged fullness• Bloating• Nausea/vomiting- often of chewed but undigested food• Abdominal pain- but less common in DM than in non-Diabetic

gastroparesis• Physical examination is no particularly revealing

• Remember the succussion splash??

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Diagnosis

• 1) remember to think of it!• A cause of unexplained glycemic excursions/ with both lows and highs

related to erratic gastric emptying

• 2) exclude other diagnoses/ often necessitates endoscopy• 3) technetium/egg gastric emptying study• 4) capsule enteroscopy• 5) gastric electrical activity study- don’t try this in your office

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Treatment

• Very challenging because improving glycemic control is imperative!

• Avoid oral agents because of uncertain absorption and because even patients with Type 2 have advanced disease

• Basal/bolus regimens either pump or injection delivered• Bolus should be administered post-prandially• Regular insulin may be preferable• BUT: the most important component of treatment is dietary!

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Nutritional therapeutic approach

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Pharmacotherapy

• Prokinetics• Metoclopramide 5-20 mg TID ac• Erythromycin 125-250 QID• Domperidone- through Canada or through FDA by IND

• Anti-nausea• Ondansetron 4-8 mg BID

• Anxiolytics• Lorazepam 0.5-1 mg QID• Alprazolam 0.25-0.5 mg TID

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Invasive therapies

• Gastric electrical stimulation• Gastric pacing• Botulinum toxin injection• Pyloric dilation

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Nutrition and GastroparesisFebruary 16, 2017

Karmella Thomas, RDN, LD, CDE

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Nutrition’s role and goals• Support glycemic control

• Hyperglycemia can slow the rate of gastric emptying• Food modifications

• Small, frequent meals, low-fat, low-fiber, liquid meals• Jejeunostomy enteral feedings (severe cases)• Adjustments in bolus insulin

• Consideration for taking insulin after eating vs before• Exercise

• Postprandial exercise (walking) to increase solid-meal gastric emptying

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Controlled nutrition trails?

• No controlled trails of varying food modifications for treatment of gastroparesis is currently available.

• Nutrition recommendations are based on professional judgment and clinical practice as well as logical interpretation of gastric physiology

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Common food modifications

• Small, frequent meals that are nutritionally balanced • Concerns are early satiety and bloating that can reduce

quantity of food and frequency of intake • risk of compromised nutritional status

• Consumption of more liquid calories later in the day with solids early in the morning

• Liquid meals or blenderized meals late in the day

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Common food modifications

• Chew foods well• Sit up during the meal and for at least 1-2 hours after each

meal• Reduced fat diet

• Fat can inhibit gastric emptying in a solid meal (less in liquid form)

• Lower fiber content• Fibrous vegetables and fruits (oranges and broccoli)• Increased risk of blockage from undigested foods

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Recommended Foods

• Milk• Instant breakfast• Milkshakes and smoothies• Yogurt• Puddings and custard• Pureed foods• Soup

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Common nutrition diagnoses

• Inadequate vitamin intake• Inadequate mineral intake• Impaired nutrient utilization• Excessive fiber intake• Altered gastrointestinal function• Unintended weight loss

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Considerations• Supplements for possible magnesium, iron and ferritin,

vitamin B-12, 25-hydroxyl vitamin D • chewable or liquid versions

• Enteral or parenteral nutrition support• Gastric failure or inability to maintain weight via oral route• Unintentional weight loss, especially in 6 month time

period• High Risk: BMI under 18.5 kg/m2 or BMI 18.5-20 kg/m2

and 5-10% weight loss• Medium Risk: BMI 18.5-20 kg/m2 and less than 5% weight

loss or BMI above 20 kg/m2 and weight loss of 5-10%

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Sample MenuBreakfast 1 c cooked oatmeal (2 carbohydrate servings)

½ c non fat milk (1/2 carbohydrate serving)½ cup orange juice (1 carbohydrate serving)1 scrambled egg

Morning Snack 1 packet instant breakfast mix (1.5 carbohydrate serving)1 cup skim milk (1 carbohydrate serving)

Lunch 1 cup vegetable soup (1 carbohydrate)6 soda crackers (1 carbohydrate)½ c applesauce (1 carbohydrate)½ c nonfat milk (1/2 carbohydrate)

Afternoon snack 6 oz plain yogurt (1 carbohydrate)1 small banana (1 carbohydrate)

Evening Meal 3 oz baked fish½ cup mashed potatoes (1 carbohydrate) and 1 tsp margarine1 c cooked carrots (1 carbohydrate)½ cup skim milk (1 carbohydrate)½ c canned fruit, in juice (1 carbohydrate)

Evening Snack 1 cup pudding (2 carbohydrates)

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