FAQs-
How does diabetes affect the gastrointestinal system ?
How does diabetes affect gastrointestinal motility ?
What disorders of the GI system are usually found in diabetes ?
Does diabetes cause stomach issues ?
For answers to all these questions pl go through the article given below –
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.
Diabetes is the most common known cause of gastroparesis.
Medicines can help gastroparesis but not completely cure it.
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.
Symptoms of gastroparesis –
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
Medicine line of treatment –
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-
Effects of diabetes on gastrointestinal system
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.
Following is the grading system for 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:
-in relation to –Effects of diabetes on gastrointestinal system-
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
-in relation to –Effects of diabetes on gastrointestinal system-
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:
-in relation to –Effects of diabetes on gastrointestinal system-
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
-in relation to –Effects of diabetes on gastrointestinal system-
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:
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.
Diabetes can have a significant impact on the gastrointestinal (GI) tract, leading to a variety of signs and issues that are collectively known as diabetic gastroenteropathy. This may have an impact on any area of the GI tract, from the esophagus to the rectum, resulting in dysmotility, changes in secretion, and other digestive problems.
Symptoms and Consequences:
Gastroparesis:
Delayed gastric emptying, a frequent gastrointestinal problem in diabetes, can result in abdominal pain, bloating, nausea, and vomiting.
Esophageal Dysfunction:
Diabetes can raise the risk of Barrett’s esophagus, gastroesophageal reflux disease (GERD), and esophageal dysmotility.
Enteropathy:
This describes harm to both the small and large intestines, which can result in symptoms such as fecal incontinence, diarrhea, and constipation.
Other Gastrointestinal Problems:
Bloating, nausea, vomiting, heartburn, and a lack of desire to eat can also be brought on by diabetes.
Bacterial Overgrowth
Delayed emptying can cause intestinal stasis, which can result in small intestinal bacterial overgrowth (SIBO) and diarrhea.
Fundamental Mechanisms:
Diabetic Neuropathy:
The GI tract’s ability to regulate digestion can be compromised by damage to its nerves, especially the vagus nerve.
Dysfunction of the Enteric Nervous System:
Diabetes can impact the enteric nervous system, which governs GI motility and secretion, resulting in dysmotility illnesses.
Oxidative Stress and Inflammation:
GI issues can also be caused by chronic hyperglycemia and the consequent oxidative stress and inflammation.
Management:
Managing Blood Sugar:
Maintaining strict blood sugar control is essential for managing gastrointestinal symptoms and avoiding additional issues.
Changes to the diet:
Gastroparesis can be managed by modifying the kind and timing of meals consumed, as well as eating smaller, more frequent meals.
Drugs:
Antidiarrheal medications and constipation treatments can resolve bowel problems, while antiemetics and prokinetic agents can assist with nausea and delayed gastric emptying.
Multidisciplinary Method:
Managing diabetic gastroenteropathy requires addressing both symptom relief and glycemic control, frequently with the help of a multidisciplinary team.
THERAPY
The management of diabetic gastroparesis should prioritize symptom reduction, evaluation of disease severity, correction of nutritional deficiencies, and exclusion of other etiologies. A grading system might be useful for directing treatment and evaluating severity.
Avoid drugs and substances that make underlying dysmotility worse whenever possible. Aluminum hydroxide antacids, anticholinergic drugs, beta-adrenergic receptor agonists, calcium channel blockers, diphenhydramine (Benadryl), histamine H2 antagonists, interferon alfa, levodopa, opioid analgesics, proton pump inhibitors, sucralfate (Carafate), and tricyclic antidepressants are examples of drugs that slow gastric emptying. Beta-adrenergic receptor antagonists and prokinetic drugs are examples of medications that speed up the emptying of the stomach. It is crucial to manage blood glucose levels because high blood glucose levels can result in gastric dysrhythmias and delayed emptying. Dietary changes and a low-dose antiemetic or prokinetic medication can assist control symptoms in mild sickness. It is beneficial to increase the amount of liquids in the patient’s diet since liquid emptying is typically maintained in gastroparesis patients with slowed solid emptying. It makes sense to advise eating smaller meals more frequently in order to reduce post-prandial fullness. Tobacco items should be avoided. Alcohol, foods high in fat or insoluble fiber, and fiber supplements can all slow down gastric emptying, so their consumption should be minimized.
Metoclopramide (Reglan) has central anti-emetic effects, making it effective for alleviating symptoms of nausea and postprandial fullness. Additionally, it enhances antropyloroduodenal coordination and raises lower esophageal sphincter pressure. About 20 to 30 percent of metoclopramide users experience side effects, some of which may be neurological (e.g., drowsiness, irritability, extrapyramidal symptoms, dystonic reactions) because the drug crosses the blood-brain barrier. Tardive dyskinesia, which causes involuntary movements of the tongue and face, is a rare, dose-dependent side effect that could be irreversible. In a technical review, the AGA discovered four little, randomized, double-blind, crossover trials that showed different levels of symptom improvement in gastroparesis patients using metoclopramide.
Erythromycin directly affects motilin receptors, smooth muscles, and enteric nerves, making it a potent prokinetic agent and motilin agonist that promotes antral contractility and speeds up stomach emptying. The majority of the available research on erythromycin for gastroparesis comes from open-label trials with fewer than 10 participants and case reports. The subpar design of the majority of studies on erythromycin would skew findings in favor of the treatment, even if erythromycin did provide a slight symptomatic benefit. However, considering its favorable safety record, erythromycin is a viable treatment choice for patients with symptoms.
The pro-motility effects of tegaserod (Zelnorm), a medicine that is only permitted for limited usage in the United States, are somewhat promising. Tegaserod has been demonstrated to accelerate gastric emptying in studies conducted in healthy individuals without gastroparesis, but there are currently no clinical trials involving patients with gastroparesis. Due to its high cost and possibility for negative side effects, tegaserod is not often advised.
Although it has been demonstrated that bethanechol (Urecholine) increases the amplitude of contractions throughout the GI tract, there is no evidence that it alleviates the symptoms of gastroparesis when used alone or in conjunction with other medications. Antiemetics, such as promethazine (Phenergan) and ondansetron (Zofran), can be given to treat the symptoms of persistent nausea.
Gastric electric stimulation is authorized for the treatment of refractory gastroparesis, although clinical trials have produced varying outcomes, with some indicating no advantage. Complications, such as gastric erosion or infection, affect 5 to 10 percent of patients. A long-term, uncontrolled, open-label follow-up study of 156 patients with an implanted electric stimulation device demonstrated substantial improvements in the symptoms of drug-refractory gastroparesis.
Total parenteral nutrition, the insertion of a gastrostomy or jejunostomy tube, botulinum toxin type A (Botox) injection into the pylorus, surgery, or gastric electric stimulation may be considered for patients who are resistant to pharmacotherapy. However, there is a lack of clinical trial data. Gastroparesis treatment options are listed.
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