Last week, a 65-year-old gentleman with diabetes was referred to me for fluctuating blood glucose values. His glucose values ranged from 40 to 400 mg/dl on the same day. He had had diabetes for 25 years and was on insulin treatment. Despite frequent adjustments of dose, his sugar levels continued to be haywire, and his HbA1c (a measure of three months blood sugar control) was high (9 per cent against the usual target of 7 per cent). He also complained of upper abdominal discomfort, nausea and occasional vomitting after meals.
It is not unusual for people with diabetes to complain of nausea and vomitting. One cause of nausea and heartburn in diabetes is a commonly used medicine, Metformin. Another is simple GERD (gastrointestinal reflux disease) which is very common in Indians. All these factors had been ruled out in this patient. Yet the problem persisted.
After a detailed clinical and diagnostic assessment, the patient was found to be suffering from a condition called diabetic gastroparesis, which literally means “partial paralysis” of the stomach and is seen in long-standing diabetes. In this condition, food stays for much longer in the stomach than it should since the stomach cannot propel the food down into the intestine as it normally does. The condition is commoner than we think and is often missed as it is not suspected.
Gastroparesis happens because the vagus nerve that supplies stomach muscles is damaged by diabetes. Typical symptoms of gastroparesis include “gastritis”, acidity and bloating after eating. Vomitting of undigested food several hours after a meal is an important, at times diagnostic clue, to the presence of gastroparesis. Some patients have chronic abdominal discomfort and pain, while others may present progressive weakness and weight loss. Because of varied transit times through the stomach, there is erratic absorption of nutrients, from the stomach and duodenum, and wide swings in blood glucose levels may be seen, as was the case in our patient. Chronic malnutrition may result because of frequent vomitting and erratic food absorption.
Dehydration may occur because of severe, uncontrolled vomitting. The quality of life of patients with gastroparesis can be seriously compromised.
Several tests are employed to confirm the diagnosis of gastroparesis. The most important among them is a gastric emptying study, done using a meal tagged with a radioactive isotope. It’s a totally safe and non-invasive test but takes four hours. A breath test is sometimes used for diagnosis. The test can show how fast your stomach empties after consuming food by measuring the amount of a particular substance in your breath. An upper GI endoscopy and ultrasound of the abdomen are also used, in particular to rule out other possible diagnoses like gall bladder stones.
More recently, electronic capsules have been developed which you can swallow and these can then send signals to an external receiver that can track the speed of movement.
What should you do if you have been diagnosed with gastroparesis? The first and foremost thing to do is modify your diet. Eating small meals at frequent intervals is the key to success. No intermittent fasting or long gaps for you. Six to seven small meals a day is the best approach. This way you will not stretch your stomach muscles and will not feel excessively bloated.
Contrary to advice given routinely to people with diabetes, food will have to be changed to low fibre, low residue. High fibre fruits and raw vegetables are best avoided. Instead, cooked vegetables and soups are recommended. Proper chewing, softer food, and more liquids (including plenty of water) are encouraged. This can be a big challenge at times because low fibre food is rapidly absorbed and can by itself cause a sharp rise in glucose levels. Your doctor will advise you how to deal with this. In addition, high fat food, sodas (“soft or cold drinks”), alcohol and smoking can increase your symptoms, so they are best avoided. One simple tip that helps many of my patients is taking a short walk after meals and avoiding lying down for at least two hours after a meal.
Several medications are used for diabetic gastroparesis. Drugs that improve motility of the gut, called prokinetics (for example Metoclopramide) are commonly used. The antibiotic Erythromycin is also useful in some cases, as it may hasten gastric emptying. Symptomatic treatments like anti-nausea and anti-vomitting drugs should be used as advised.
For most advanced cases surgical intervention may be used. The use of gastric stimulator devices is an interesting approach. Gastric by-pass surgery is an extreme measure in obese cases. Newer endoscopic procedures like pyloromyotomy may also help some patients. Tube feeding or intravenous nutrition are temporary measures for the most severe cases.
How can we prevent the development of gastroparesis? Good diabetes control, right from the initial diagnosis of diabetes, is critical. Following an appropriate diet plan accompanied by the right medication as described above will take care of the majority of symptoms of gastroparesis. It’s only rarely that one has to resort to invasive methods.
(The author is a Padma Bhushan Awardee)