Gastrointestinal Case Study
A 60-year old woman with a 10-year history of Type II diabetes presents with multiple complications including retinopathy, peripheral neuropathy and declining renal function.
She has not had the urge to eat as of recently she feels “full” after a few bites. The incidence of nausea and feeling bloated occur at least twice a day and even after a glass of water she feels bloated. She also complains of fatigue and not been able to keep up with daily chores. A radiographic gastric emptying study shows a prolonged gastric emptying time.
Diagnosis and Pathophysiology
Gastroparesis is a typical diagnosis disorder affecting people with both type 1 and type 2 diabetes; in which the stomach takes too long to empty its contents (delayed gastric emptying). The vagus nerve controls the movement of food through the digestive tract. If the vagus nerve is damaged or stops working, the muscles of the stomach and intestines do not work normally, and the movement of food is slowed or stopped. Signs and symptoms of gastroparesis include: heartburn, nausea, vomiting of undigested food, early feeling of fullness when eating, weight loss, abdominal bloating, erratic blood glucose levels, lack of appetite, gastroesophageal reflux, and spasms of the stomach wall (ADA, 2018) . These symptoms may be mild or severe, depending on the person. Gastroparesis can make diabetes worse by making it more difficult to manage blood glucose. When food that has been delayed in the stomach finally enters the small intestine and is absorbed, blood glucose levels rise.
If food stays too long in the stomach, it can cause problems like bacterial overgrowth because the food has fermented. Also, the food can harden into solid masses called bezoars that may cause nausea, vomiting, and obstruction in the stomach. Bezoars can be dangerous if they block the passage of food into the small intestine.
The most important treatment goal for diabetes-related gastroparesis is to manage your blood glucose levels as well as possible. Treatments include insulin, oral medications, changes in what and when you eat, and, in severe cases, feeding tubes and intravenous feeding. If you have gastroparesis, your food is being absorbed more slowly and at unpredictable times. To better manage blood glucose, many people work with their doctor and/or diabetes educator and dietitian to come up with a plan that may involve: Taking insulin more often, taking your insulin after you eat instead of before you eat, and checking your blood glucose more often after you eat to better match insulin to the delayed rise in blood glucose (ADA, 2018). The patient would be encouraged to change eating habits to assist with managing symptoms of gastroparesis such as: Eat four to six meals per day, drink high-calorie liquids, limit alcohol and carbonated beverages, take a daily multivitamin, if tolerated, limit certain meats and dairy, eat well-cooked vegetables and fruit to lower the amount of fiber they contain, eat mostly low-fat foods, avoid foods that have a lot of fiber, like broccoli and oranges, ensure there’s adequate time after meals before lying down for bed, substitute solid foods for pureed or liquid foods. It can be helpful to eat less food at one time. Other helpful tips are to eat slowly, sit upright after eating, and take a walk after meals.
As a practicing practitioner, I would recommend the patient avoid high-fat and high-fiber foods. High fat foods take longer to digest and can increase symptoms from slowed digestion. Fiber can be difficult to digest and it may be possible that the undigested fiber can form bezoars (a solid mass of undigested food that gets stuck in the digestive tract (or gut) causing a blockage). Talk to your doctor or registered dietitian for more guidance that will meet your personal lifestyle and needs.
Medications such as Metoclopramide (Reglan), Erythromycin and Motilin can stimulate stomach muscles and help with digestion. Reglan (drug of choice) relieves symptoms of slow stomach emptying in people with Diabetes; prevent nausea and vomiting that can happen with cancer chemotherapy, prevent nausea and vomiting that may happen after surgery. As a practicing practitioner, I would start the patient on Reglan 5 mg four times a day, 30minutes before meals and at bedtime. The patient would be educated to report any signs of drowsiness, dizziness, tiredness, trouble sleeping, agitation, headache, and diarrhea that may occur (Medicinenet, 2018). Effectiveness of the medication would be reassessed within a month; and then quarterly. If there are any complications, the patient would be evaluated for a more effective treatment regimen.
With an increasing prevalence of gastroparesis amongst Diabetics, practicing practitioners need to be able to recognize long term effects of neuropathy on the gastrointestinal tract. This neuropathy is problematic in achieving blood glucose control. Gastroparesis is often overlooked in differential diagnoses due to the variety of symptoms related to other diseases, medications or conditions. Early testing should be done, in the early stages of cardinal signs and symptoms that align with this illness; to ensure an effective treatment regimen is prescribed.
American Diabetes Association (ADA, 2018). Gastroparesis. Retrieved June 1, 2018 from http://www.diabetes.org/living-with-diabetes/complications/gastroparesis.html
Medicines.net (2018). Metoclopramide (Reglan). Retrieved June 1, 2018 from https://www.medicinenet.com/metoclopramide-oral/article.htm