Effects of diabetes on gastrointestinal system

Image for effects of diabetes on gastrointestinal system                                                                                                             Effects of  diabetes on  gastrointestinal system-means effects of diabetes specifically on the gut.

If  an  individual  is  suffering  from nausea, heartburn, or bloating one  possibility of diabetes should  always  remain  in  mind.

And  vice-versa  if  an  individual  is  already  diagnosed  with  diabetes  and  he is  having  symptoms  of nausea, heart  burn, bloating  then these  symptoms  should not be ignored. It  indicates  that  the  individual  is  suffering  from  gastroparesis .

Gastroparesis is a condition that affects how you digest your food.

It  is  due  to  affection  of  the  nerve  that  innervates  the  stomach.

Thus  peristalsis  is  affected  and  gastroparesis  results .

In  this  case  opinion  should  be  taken  from  a  physician  (MD-General Medicine) or  a  Gastroenterologist .

What is  Gastroparesis ? -in relation to-Effects of diabetes on gastrointestinal system

Normally  during  peristalsis the  stomach  muscles  tighten  so  as to  move  the  food  down  the  gastrointestinal  tract  .

However  in  diabetes  due  to  damage  to  the  nerves  these  muscles  tighten  less  or  do  not  move  at  all.

Thus  food  takes  comparatively  longer  time  to  move  down  the  stomach.

This  affects  assimilation (time  taken  for  the  body  to  absorb  food  increases) .

Certain  doses  of  insulin  are  required for  certain  doses  of  food, so the  dose  of  insulin  secreted by the  pancreas  and the  dose of  food  absorbed does not  match .

This  can  lead to  malnutrition

Frequent vomiting  is a  symptom of  gastroparesis which  can  cause  extreme thirst  and  dehydration.

Feeling  stuffed  after heavy food .

Feeling  abdominal pain, bloating  discomfort even  after  intake of small amount of  food.

Nausea vomiting and  heart  burn poor appetite can  also  occur.

If  any  of these  symptoms  occur consultation  should be done  with  a  physician (MD General Medicine) or  a  Gastroenterologist.

Management of  gastroparesis– in relation to –Effects of diabetes on gastrointestinal system

Medicines will  help  but  cannot  completely  cure  gastroparesis.

Following  actions  should be  taken –

Always try to  keep  blood  sugar  as  close to  normal  range .

Frequent small meals  should be  taken that  are low  in  fat and  fibre .

The  reason  this  should be  done  is  that  fat  and  fibre delay  the  emptying  of the  stomach and  the  symptoms  get  aggravated.

To  drink  plenty of  water -minimum  7-11 cups  of  water  per  day.

The  physician  or  Gastroenterologist from whom  the  treatment  is  taken  should  be  informed  about  all  the  medications  which  are  going  on  at  present so  that  any  drugs  interactions  contraindications, adverse effects of  drugs  should be taken  care of.

Any  acidity  causing  drugs  should be  informed  to  the  doctor.

Alcohol, smoking  and  other  addictions  should be  given  up.

Regular  physical  activity  minimum  80 minutes  per  day.

Consultation  with  dietitician regarding  proper  diet  advice.

Oral  manifestations- in relation to-

Xerostomia-dryness of  mouth  is  found  in  34-51 percent of diabetes  patients.

Hyposalivation  can  result  in  difficulty in  swallowing, speaking  ,eating .

Sialosis (diffuse  swelling  of  parotid  glands which  is  non -neoplastic,non inflammatory, diffuse  asymptomatic  is  common  in  patients of diabetes .

Taste dysfunction, oral  candidiasis( fungal  infection) is  common  in  patients of diabetes .

Deep  neck  bacterial  infection.

Recurrent  aphthous  stomatitis.

Oral  infection.

Periodontal  problems,

Dental  caries

Tooth  loss.

Lichen  planus

Good oral  hygiene  and  strictly controlling  blood  sugar  can  minimize these  effects.

These  things  can  decrease  the  morbidity  and  increase the  quality of  life.- in relation to-Effects of diabetes on gastrointestinal system

Oesophageal  candidiasis -This  may be  found  in diabetic  patients and  usually  presents  with  painful  swallowing  and  dysphagia .

Diagnosis of  oesophageal  candidiasis  is  by  fibre optic  oesophagoscopy  and  biopsy by  gastroenterologist.

Treatments include  strictly  controlling  blood sugar and  and  anti fungal  treatment.

Oesophageal  dysmotility -Incidence  of  oesopphageal  dysmotility  in  diabetes  patients  is  61 percent. In  this  there  is  reduced  peristalsis  or  no  peristalsis.

It  is  usually  asymptomatic  but  may  cause  regurgitation  of  food  particles and  dysphagia.

It  is  diagnosed  by  manometry.

Patient  is advised  diet  modifications  and  to  drink  fluids  immediately  after  pills.

Black  oesophagitis -It  is  acute  oesophageal  necrosis  and  it  is  rare  complication of acute  diabetic  ketoacidosis.

Oesophageal  perforation and  stricture  can  occur.

Acute  oesophageal perforation  has  a  poor  prognosis.

Management  of  acute  oesophageal  perforation  includes  oesophageal  rest, gastric  acid  suppression and  treating  the  underlying  cause.

GERD (Gastrooesophageal  reflux  disease)   is more  common  in  type  -2 diabetes  as compared  to  non  diabetics.

Erosive  oesophagitis  is  more  common  in  diabetic individuals  with  neuropathy .

Gastroesophageal  disease – in relation to-  Effects of diabetes on gastrointestinal system –is  diagnosed  by  clinical  features, treated  by  proton  pump  inhibitors ,or  H2 blockers  and  by  lifestyle  modifications.

Several  factors  like vagus  nerve  dysfunction,

  glycemic  excursions,  decrease in expression  neuronal  nitric  oxide  synthase with  in  the  myenteric  plexus  on  the  enteric nervous system, disturbance/ loss of interstitial cell of Cajal (specialized pacemaker cells),

and the  existence of proinflammatory  state  due  to  excessive oxidative  stress is  responsible  for gastroparesis in diabetic gastroparesis .

 Drugs  used  in  Diabetes Mellitus to  control  blood sugar,  such  as  GLP1  receptor  agonists  and amylin  analog  (pramlinitide)  are responsible for delayed gastric emptying.

Diagnosis  of  gastroparesis  is  done  by  upper  GI  endoscopy.

Technetium-  labelled  gastric  emptying scintigraphy  test  with  low-fat,  egg-white, albumin-based  meal  is  the best for diagnosis  of  diabetic  gastroparesis

Intestinal  complications of  diabetes -in relation to-Effects of diabetes on gastrointestinal system-

The small  intestine  transit  time  in  patients of diabetes mellitus is abnormal such as slow or rapid and  up  to  80%  patients  with  diabetic gastroparesis  patients do  not  have intestinal  peristalsis  in the  normal  range.

 Due  to  involvement  of enteric  nerves  of  the  small  intestine  in diabetes, there is abnormal motility, secretion, or absorption in the small intestine which leads to  delayed peristalsis and  stagnation  of fluids, resulting  in  bacterial  overgrowth and  infection  bloating,  diarrhea  and  abdominal pain.  Small  intestinal  bacterial  overgrowth  is found  in  up  to  40% of  diabetic  patients with diarrhea .  Though  the  diagnostic  test requires  small-bowel  intubation,  aspiration  of small intestinal  fluid and  quantitative  cultures of fluid, Breath hydrogen testing and the (14C)-D-xylose  test is  useful in diagnosis  of SIBO .

 SIBO is treated by short term or intermittent (in case of recurrent SIBO) use of antibiotics.  Rifaximin  is  the  mostly used in SIBO treatment.

Diabetes is associated with various complications involving the gastrointestinal tract-in relation to –Effects of diabetes on gastrointestinal system- biliary tree, pancreas, and liver ,stomach, intestine.

 Up to 75% of patients with longstanding diabetes report chronic or intermittent GI complaints resulting from abnormal sensory or motor function of the gut. Patient with diabetes may have altered function of multiple organs of the  digestive system .

Diabetic Gastroparesis/Gastropathy- in relation to –Effects of diabetes on gastrointestinal system-

Definition: Diabetic gastropathy is a term used to collectively describe all disorders that occur as a result of autonomic neuropathy affecting the stomach. The most severe disorder is gastroparesis which is defined by delayed gastric emptying in the absence of mechanical obstruction. Approximately 40% of patients with type 1 diabetes and 10-20% of patients with type 2 diabetes will develop gastroparesis.

Grade 1–symptoms controlled with maintenance of weight and nutrition on a standard diet

Grade 2–moderate symptoms with partial control on prokinetic and antiemetic medications and ability to maintain nutrition with dietary modifications

Grade 3–refractory, uncontrolled symptoms requiring frequent emergency department and clinic visits or hospitalizations and/or inability to maintain nutrition orally

Symptoms and Signs:- in relation to –Effects of diabetes on gastrointestinal system- Patients with diabetic gastropathy may present with nausea and vomiting (45%), abdominal pain or discomfort (20%), bloating (7%), early satiety, and postprandial fullness. Vomiting typically occurs 30-60 minutes after eating but may occur up to 8 hours after oral intake. Patients with frequent or refractory vomiting may have loss of dental enamel, GI bleeding from tearing of the gastroesophageal junction (Mallory-Weiss tear) or hemorrhagic gastropathy. Abdominal pain is typically postprandial and described as vague burning, crampy, sharp, or pressure-like. Symptoms in diabetic gastroparesis are chronic in >50% of patients but may also occur in a cyclical nature in up to 10%.

The Gastroparesis Cardinal Symptom Index (GCSI) is a validated symptom survey composed of nine symptoms and often used in clinical investigation and patient care (Table II). There are no pathognomonic signs in patients with diabetic gastroparesis but in severe cases may include a succussion splash on auscultation.

Small Intestinal Bacterial Overgrowth– in relation to –Effects of diabetes on gastrointestinal system-

Definition: Small intestinal bacterial overgrowth (SIBO) is a condition that develops as a consequence of excessive bacteria colonized in the small intestine. Bacterial metabolism of food residue delivered into the small intestine promotes generation of gases (hydrogen, methane) and other by-products .

Patients with GI motility disorders (e.g., gastroparesis, small bowel dysmotility), such as those seen in patients with longstanding diabetes due to injury of the enteric nervous system, are having  higher  possibilities for developing SIBO.

Symptoms and Signs:-in relation to –Effects of diabetes on gastrointestinal system- Symptoms of SIBO include bloating, distention, flatulence, eructation, abdominal discomfort, diarrhea, or weight loss. The predominant symptoms depends on the type of microbial flora present in the individual patients. Patients with bacteria that metabolize carbohydrates to short-chain fatty acids and gaseous by-products.Such individuals primarily report bloating symptoms. On the other hand, bacteria that metabolize bile salts to insoluble compounds result in diarrhea or other  clinical features of fat malabsorption. The physical examinstion in most patients with SIBO shows visible abdominal distention on inspection or  on percussion.

Diabetic Constipation -in relation to –Effects of diabetes on gastrointestinal system-

 Diabetic constipation shows presence of decreased stool frequency, straining with defecation, lumpy or hard stools, sensation of incomplete evacuation, or need for enema for defecation. Constipation is reported in approximately  66 percent of patients with diabetes.Diabetic constipation is a result of neuropathy leading to decreased colonic motility and decreased gastrocolic reflex.

Symptoms and Signs: Patients with diabetic constipation report a range of bowel disturbances including infrequent passage of hard stools and  they  have  to  strain  a  lot further passage of  stools .

Additional clinical features due to constipation may include bloating, distention, abdominal pain, discomfort, and fullness. Physical examination -On digital anorectal examination one  may  find hard, firm stool in the rectal vault.

Diabetic Diarrhoea -in relation to –Effects of diabetes on gastrointestinal system-

 Diabetic diarrhea means passage of frequent or loose stools occurring as a consequence of longstanding diabetes. The pathogenesis of this condition is multifactorial  Diets with large amounts of poorly absorbed carbohydrates (e.g., sorbitol that is commonly used in sugar free foods) can cause  diarrhea due to osmosis. Patients with SIBO may have mucosal injury, malabsorption, indigestion problems. Increased delivery of unconjugated bile acids to the colon triggers fluid and electrolyte secretion. Type 1 diabetes is associated with other autoimmune disorders (e.g., celiac disease, Addison’s disease) which commonly cause diarrhea.

 Finally, a subset of diabetics with diarrhea exhibit a true secretory diarrhea due to loss of balance between cholinergic intestinal secretion and impaired adrenergic absorption.

Symptoms and Signs:

Diabetics with diarrhea will  complain about passage of loose and/or frequency of stools is  increased. Nocturnal symptoms are dependant on the underlying etiology for the patient’s diarrhea. If there is associated malabsorption due to associated SIBO, celiac disease, or pancreatic insufficiency, patients may also experience bloating, distention, flatulence, weight loss, or steatorrhea. Many patients with high volume liquid stool output will experience fecal incontinence.

Fecal Incontinence

Fecal incontinence refers to inadvertent expulsion of feces in  which  voluntary  control  is  lost. In diabetic patients, this complication is due to affection of  nerves that may affect both the internal and external anal sphincters. Symptoms may be further increased by the presence of loose or liquid stools.

Symptoms and Signs:

Diabetics with fecal incontinence may have varying degrees of symptoms, ranging from minor soiling to excretion of large amounts of stool and adult incontinence undergarments are  required in  this  case.

In patients with associated rectal sensory neuropathy, the presence of stool in the rectum may be unrecognized prior to its uncontrolled passage.

 Episodes of fecal incontinence may occur during sleep.

Digital rectal examination of the diabetic with fecal incontinence may show presence of anal neuropathy including decreased anal tone, weak squeeze pressure . Loss of the anal wink reflex is there.

Biliary manifestations of diabetes

Choledocholithiasis -For this  there is  requirement of  endoscopic retrograde cholangiopancreatography with sphincterotomy and stone extraction. Cholecystectomy is a  procedure  that  many be  required in  a patient  with an episode of choledocholithiasis or cholecystitis.

Pancreatic enzyme supplementation is given with meals and snacks in patients with evidence of fat malabsorption.

Hepatic:  At present  even  in  modern times there are currently no medications to specifically treat hepatic steatosis. The present line of management is  to optimize glycemic and lipid control, diet, exercise, and weight loss. Patients with progression to cirrhosis will  require liver transplantation in  the  end.