Diabetic Gastroparesis

When diabetes affects the stomach’s ability to empty properly, food can sit too long, causing uncomfortable symptoms and making blood sugar control even more challenging.

Table of contents

• What is diabetic gastroparesis?
• What causes this condition?
• How common is it?
• Signs and symptoms
• Possible complications
• How doctors diagnose gastroparesis
• Treatment approaches
• Dietary changes and management
• Living with diabetic gastroparesis

What is diabetic gastroparesis?

Gastroparesis is defined as a delay in gastric emptying (when the stomach empties) without any evidence of mechanical blockage^[1]. In simple terms, it means the stomach takes too long to empty its contents into the small intestine^[2].

Diabetic gastroparesis is a potential complication that occurs in the setting of poorly controlled diabetes. It results from problems in the coordination and function of the autonomic nervous system (the part of your nervous system that works automatically), neurons (nerve cells), and specialized pacemaker cells of the stomach and intestine, as well as the smooth muscle cells of the gastrointestinal tract^[1].

In diabetic gastroparesis, hyperglycemia (high blood glucose, a type of sugar that your body uses for fuel) can harm your stomach muscles and nerves of the interstitial cells of Cajal, which help your stomach muscles move. Diabetes can also injure your blood vessels, meaning your nerves do not get the oxygen and nutrients they need^[3].

Although diabetic gastroparesis is more common in people with type 1 diabetes, people with type 2 can also get it^[2].

What causes this condition?

Hyperglycemia, commonly seen in poorly controlled diabetes, has been associated with diabetic gastroparesis resulting from neuropathy (nerve damage) in the setting of chronic hyperglycemia. This damage does not resolve with improved blood sugar control. However, acute hyperglycemia, though it can also result in delayed gastric emptying, is often reversible with improved blood sugar control^[1].

Gastric emptying requires coordination of several processes. The stomach needs to relax and contract at the right times, while the valve at the bottom of the stomach and the beginning of the small intestine need to coordinate their movements. This coordination requires interactions between the enteric and autonomic nervous systems, smooth muscle cells, and the stomach’s specialized pacemaker cells (interstitial cells of Cajal)^[1].

The gastric motor problems encountered in the setting of diabetes may occur as a result of autonomic neuropathy (affecting both sympathetic and parasympathetic nerves), enteric neuropathy (affecting both excitatory and inhibitory neurons), abnormalities in the interstitial cells of Cajal, acute blood glucose fluctuations, use of certain diabetes medications, or psychosomatic factors. Most patients with diabetes tend to have problems at multiple points in the process of gastric emptying^[1].

The vagus nerve controls how quickly your stomach empties. When it’s damaged, digestion slows down, and food stays in your body longer than it should^[2]. This nerve can be damaged from long-term high blood sugar from diabetes that is not well treated^[16].

How common is it?

Although idiopathic gastroparesis (gastroparesis with no known cause) is the most common form of gastroparesis, diabetes is the most common disease associated with the condition^[1]. Diabetes is the most frequently identified disease linked to gastroparesis^[3].

Gastroparesis is more prevalent in patients with type 1 diabetes than in those with type 2 diabetes. The 10-year cumulative incidence of diabetic gastroparesis has been estimated to be 5.2% in patients with type 1 diabetes and 1% in those with type 2 diabetes^[5]. The prevalence of diabetes-associated gastrointestinal symptoms is 5 to 12%^[5].

Most people with gastroparesis have had diabetes for at least 10 years and also have other complications related to the disease^[2]. Gastroparesis, a form of autonomic neuropathy, is most commonly seen in people who have had diabetes for more than 10 years and who have already developed other microvascular complications (problems with small blood vessels)^[5].

In a study conducted in Olmsted County, Minnesota, the age-adjusted incidence rate of gastroparesis was 2.4 per 100,000 person-years in men and 9.8 per 100,000 person-years in women^[5].

Signs and symptoms

If you have diabetic gastroparesis, your symptoms may include^[2]:

• Heartburn or reflux (backup of stomach contents into the esophagus)
• Nausea
• Vomiting (in severe cases, this may happen daily)
• Trouble controlling blood sugar
• Feeling full quickly when eating
• Abdominal bloating
• Poor appetite and weight loss or weight gain

The most common symptoms are early satiety (feeling full after eating just a few bites), nausea, bloating, abdominal pain, and vomiting^[5]. You may feel full almost immediately and for a long time after eating. You may have a stomachache, feel nauseous, or throw up. Your stomach may feel bloated or stretched, and you may have acid reflux as a side effect^[6].

Once the symptoms from gastroparesis begin, they typically persist and are stable over 12 to 25 years. This is true even when blood glucose levels have been controlled^[5].

Possible complications

Food that stays in your stomach too long can spoil and lead to the growth of bacteria. Undigested food can harden and form a lump called a bezoar. It can block your stomach and keep what you eat from moving into the small intestine^[2].

Gastroparesis can make it hard to control diabetes. When food finally does leave your stomach and enters the small intestine, your blood sugar goes up, too. Also, the vomiting that can come with diabetic gastroparesis can leave you dehydrated^[2].

Diabetic gastroparesis can cause^[3]:

• Severe dehydration or loss of water and electrolytes (minerals found in the body) from vomiting that does not stop
• Esophagitis, pain and irritation in the esophagus (the tube that links the mouth and the stomach)
• Bezoar (a small mass of food, fiber, or other substances in the stomach), which can cause nausea, vomiting, or a blockage, or stop the body from using some medicines right away
• Malnutrition, which happens when the body does not get the vitamins, minerals, or nutrients it needs. This can lead to weight loss and raise the risk for infection
• Worsening quality of life

Although there is no evidence to date that diabetic gastroparesis increases mortality, this complication substantially impairs all aspects of life^[5].

How doctors diagnose gastroparesis

Your doctor will ask about your symptoms. They’ll also do a physical exam, and they may check your blood sugar. They might also suggest other tests^[2].

Scintigraphy is the main test used to diagnose gastroparesis. This test, also called a gastric emptying scan, involves eating a light meal, such as eggs and toast, that has a small amount of radioactive material in it. A scanner follows the movement of the radioactive material. The scanner goes over the belly to show the rate at which food leaves the stomach. This test takes about four hours. If the scan shows that more than half of the meal is still in your stomach after 1.5 hours, or if more than 10% of the meal remains after 4 hours, you have gastroparesis^[2][9].

Other tests may include^[2]:

• Barium X-ray: You drink a liquid (barium), which coats your esophagus, stomach, and small intestine and shows up on X-rays. This test is also known as an upper GI (gastrointestinal) series or a barium swallow
• Barium beefsteak meal: You eat a meal with barium in it, and the doctor uses an X-ray to watch how long it takes you to digest the food. That tells your doctor how quickly your stomach empties
• Breath tests: You consume a solid or liquid food that has a substance that your body absorbs. In time, the substance shows up in your breath. The amount of substance in your breath shows how fast your stomach empties^[9]
• Upper gastrointestinal endoscopy: This procedure is used to see the tube that connects the throat to the stomach (esophagus), the stomach, and beginning of the small intestine. It uses a tiny camera on the end of a long, flexible tube. This test can also diagnose other conditions that can have symptoms like those of gastroparesis^[9]

Treatment approaches

How doctors treat gastroparesis depends on the cause, how severe your symptoms and complications are, and how well you respond to different treatments. Sometimes, treating the cause may stop gastroparesis. If diabetes is causing your gastroparesis, your health care professional will work with you to help control your blood glucose levels^[10].

Controlling your diabetes is one of the most important things you can do to improve your stomach function and symptoms. When your diabetes is under control, your risk for other problems throughout your whole body lessens, too^[3].

There is no cure for gastroparesis, but the condition can be managed. With medicines, changes to your diet, and other forms of treatment, you can learn to take charge and control your condition^[3].

Medicines

Your doctor may prescribe medicines that help the muscles in the wall of your stomach work better. He or she may also prescribe medicines to control nausea and vomiting and reduce pain^[10]. Commonly prescribed prokinetic agents (medicines that help move food through the digestive system) include metoclopramide, domperidone, and erythromycin. Between 25% to 68% of symptoms are controlled by prokinetic agents^[12].

Controlling blood glucose levels

If you have gastroparesis and diabetes, you will need to control your blood glucose levels, especially hyperglycemia. Hyperglycemia may further delay the emptying of food from your stomach. Your doctor will work with you to make sure your blood glucose levels are not too high or too low and don’t keep going up or down. Your doctor may recommend taking insulin more often, or changing the type of insulin you take; taking insulin after, instead of before, meals; and checking your blood glucose levels often after you eat, and taking insulin when you need it^[10].

Advanced treatments

In addition, gastric electrical stimulation has been shown to improve symptoms, reduce hospitalizations, reduce the need for nutritional support, and improve quality of life in several studies^[12].

Dietary changes and management

Changing your eating habits can help control gastroparesis and make sure you get the right amount of nutrients, calories, and liquids. Getting the right amount of nutrients, calories, and liquids can also treat the disorder’s two main complications: malnutrition and dehydration^[10].

Your doctor may recommend that you^[10]:

• Eat foods low in fat and fiber
• Eat five or six small, nutritious meals a day instead of two or three large meals
• Chew your food thoroughly
• Eat soft, well-cooked foods
• Avoid carbonated, or fizzy, beverages
• Avoid alcohol
• Drink plenty of water or liquids that contain glucose and electrolytes, such as low-fat broths or clear soups, naturally sweetened, low-fiber fruit and vegetable juices, sports drinks, or oral rehydration solutions
• Do some gentle physical activity after a meal, such as taking a walk
• Avoid lying down for 2 hours after a meal
• Take a multivitamin each day

If your symptoms are moderate to severe, your doctor may recommend drinking only liquids or eating well-cooked solid foods that have been processed into very small pieces or paste in a blender^[10].

Fat and fiber are essential, but they can slow down digestion. This is what leads to discomfort and fullness. Fat naturally slows stomach emptying. So, choosing foods labeled “low fat,” “nonfat,” or “fat-free” may help with symptoms. Fiber also slows stomach emptying^[17].

The dietary modifications for gastroparesis can be really challenging for patients. Because they need to eat smaller snacks and avoid larger meals, these changes can also impact social engagements around mealtimes and enjoyment of those occasions^[15].

Living with diabetic gastroparesis

Diabetic gastroparesis is a chronic condition. There is no cure, but the condition can be managed^[3].

Tips to make the most of your diabetes management plan^[3]:

1. Understand the medicines you are taking and take them exactly as directed
2. Know what your target blood glucose level is and what to do if your numbers are out of range. Check your blood glucose levels as often as your health care provider recommends and keep a record
3. Watch for signs and symptoms of high blood glucose
4. Follow your meal plan and be aware of foods that can cause your blood glucose to go up
5. Be as physically active as you can
6. Have a sick-day plan and follow it

Feelings of depression, anxiety, and stress are commonly reported in people with the condition. Having the right support can help you cope with the disease and know that you are not all alone. Talking to a support group or therapist can help you get through the difficult times^[15].

People with gastroparesis talk about how it leaves them feeling overly full, despite having hardly eaten. Each bite of food could send their stomach down a difficult road riddled with belly pain, nausea, and vomiting. Gone are the days of anticipating the joyful pleasure of eating. For many people with the condition, learning what to eat and when requires a certain discipline and knowledge that can feel exhausting at times^[15].

Chances are that your gastroparesis symptoms ebb and flow, with some days being better than others. Even some times of day being better than others. That’s normal. Listening to your body’s cues to guide your diet day to day is important^[17].