Effects of diabetes on gastrointestinal system-means effects of diabetes specifically on the gut.
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 ?
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-
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.
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.
Good oral hygiene and strictly controlling blood sugar can minimize these effects.
These things can decrease the morbidity and increase the quality of life.
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 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 –
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, 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 .
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: 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
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: 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 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 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 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.
For symptoms of diabetes pl click on the link given below
For effects of diabetes on skin -part-1 pl click on the link given below
For effects of diabetes on skin part -2, pl click on the link given below
For effects of diabetes on wounds and infections pl click on the link given below
For effects of diabetes on blood vessels pl click on the link given below
For effects of diabetes on vision pl click on the link given below
For effects of diabetes on kidneys pl click on the link given below
For effects of diabetes on nervous system pl click on the link given below