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October 2012

Management Of Gastrointestinal Issues In Diabetics

Dr Shravan Bohra 
Gastrointestinal (GI) problems in diabetics are common but they are not commonly recognized in clinical practice. The duration of diabetes and the degree of sugar control are major determinants in the incidence and severity of GI problems.
The entire GI tract can be affected, including the mouth, food pipe, stomach, small intestine, colon, liver, and pancreas, leading to a variable symptom complex. Those with insulin dependent diabetes Dr Shravan Bohra of long duration are at a higher risk for various gastrointestinal symptoms. Good control of diabetes is very important for relief from almost all the symptoms.
Commonly Observed GI Problems In Diabetics
  • GERD: Acid reflux in the food pipe called reflux oesophagitis.
  • Gastroparesis: Fullness/distension of the stomach after meals.
  • Enteropathy: Involvement of small/ large intestine, leading to distension of the abdomen after food or chronic diarrhoea/constipation.
Gastroesophageal Reflux Disease (GERD)
Overall, about 40 per cent of diabetics report as regularly suffering from at least one symptom of acid reflux disease, with 30 per cent experiencing heartburn at least once a week. This is more common in diabetics who have lived with the disease for more than 10 years and are exhibiting features of neuropathy. Treatment includes lifestyle modifications.
  • If you smoke, you must stop it. Also, reduce alcohol consumption
  • Avoid foods and beverages that worsen the symptoms
  • Lose weight if overweight
  • Reduce stress
  • Avoid certain medications and also avoid unnecessary medications
  • Eat small, frequent meals
  • Wear loose-fitting clothes
  • Avoid lying down before 3 hours after a meal
  • Raise the head of your bed about 6 to 8 inches by securing wood blocks under the bedposts
(Note: Foods which worsen GERD symptoms include caffeinated or carbonated beverages, chocolate, acidic foods such as tomatoes, oranges, and orange juice, spicy foods, and fatty or fried foods, mint, garlic and onions.)

Medications for GERD: Antacids for minor symptoms are easily available over the counter. For persistent reflux symptoms with heartburn, drugs like omeprazole (omez), pantoprazole are more effective. These are generally safe and most patients may require this for long term.

Gastroparesis
Twenty to forty per cent of diabetics (primarily those with long duration type 1 diabetes mellitus) with other complications, develop gastroparesis. Delayed gastric emptying (also referred to as gastric stasis and gastroparesis) may manifest clinically as a variety of symptoms including nausea, vomiting, early or easy satiety, bloating, and weight loss. Severe gastroparesis can lead to poor control of blood glucose concentrations and it can be associated with aspiration of gastric contents into the windpipe.

Diagnosis: During an endoscopy (gastroscopy), the presence of food in the stomach after several hours of eating favours the diagnosis of gastroparesis. Delayed emptying of barium from the stomach during barium meal study (X-ray study) also suggests gastroparesis.

The management of gastroparesis has four components: Supportive measures (eg, hydration and nutrition), optimizing sugar control in patients with diabetes mellitus, medications and occasionally surgery.

Patients should be advised to consume a low-fat diet and frequent, small meals. Oral supplementation may be effective in some, since liquids typically empty from the stomach more easily than solids, and liquid emptying is often normal even when solid emptying is markedly delayed. Liquidised or homogenised meals and liquid supplements (homogenised protein supplements dissolved in skimmed milk) with liquid vitamin supplements provide a means to deliver calories, proteins, minerals, and vitamins.Patients with persistent symptoms may require feeding through a tube inserted through the nose into the stomach/ upper small bowel.

Medications for gastroparesis: Drugs like domperidol/livosulpiride are commonly advised before meals to facilitate gastric emptying. Intravenous erythromycin is the treatment of choice for patients who cannot take oral medications. Implantation of gastric pacemaker may relieve the symptoms of gastroparesis in some difficult to treat cases.

Diabetic Enteropathy
Diarrhoea and large volume fatty stools can occur in diabetics, particularly those with advanced disease. The diarrhoea is watery and painless, occurs at night, and may be associated with faecal incontinence. Bouts of diarrhoea can be episodic with intermittent normal bowel habits or even alternating with periods of constipation.

Initial therapy should aim at correction of water and electrolyte imbalances, tight control of blood glucose, and restoration of possible nutritional deficiencies. Chronic treatment should be directed at the identified main cause of diabetic enteropathy rather than unspecific treatment on empirical grounds.

Patients with bacterial overgrowth should be treated with antibiotics for about a week. Biofeedback may help some cases where medicines have failed to control the symptoms. Fibre supplementation with bran like products, as well as a high-fibre diet, increases the water content for bowel movement and may relieve constipation. Mild laxatives and stool softeners often help as well.
Dr Shravan Bohra is Chief Gastroenterologist, Apollo Hospitals International Ltd, Ahmedabad.