Diabetes Related Gastrointestinal Issues

By Gastroenterology Associates of S.W. Florida, P.A. –

Diabetes has become a common disorder affecting a large population of Americans.  As the incidence of diabetes increases, so have the gastrointestinal complications associated with the disease.  Some of the more common GI issues that are found include diabetic gastroparesis, diarrhea, constipation, fecal incontinence, and non-alcoholic fatty liver disease.

The majority of the complications of diabetes that affect the GI tract are due to neuropathy that affects the nervous system in the GI tract. This is often related to how long a patient has been a diabetic but is also related to how well the patient manages his or her blood glucose levels.

GASTROPARESIS
Gastroparesis is a common finding in diabetic patients.  This occurs due to delayed gastric emptying of the stomach causing bloating, vomiting, abdominal pain, and fullness after meals.  In most diabetic patients, good blood sugar control will reduce these symptoms.

The diagnosis of gastroparesis is made by a gastroenterologist who will perform a physical examination, a medical history, and order blood work. This is usually followed by an upper endoscopy (referred to as an EGD) to rule out other sources of the symptoms.  Sometimes a barium study is also performed to rule out any kind of intestinal blockage and an ultrasound is often done in a patient who has symptoms of possible gallbladder problems.  Finally, the true confirmation of gastroparesis is accomplished by having a gastric emptying scan done.  This test involves ingesting a meal, usually scrambled eggs, that are labeled with a tracer that shows up on radiology scans.  Multiple scans are done over time after consuming the eggs and the time that it takes for food to pass through the stomach is documented.

After the diagnosis of gastroparesis is made, then the patient will be provided recommendations on how to manage the symptoms.  The most common treatment are lifestyle modifications and include eating small frequent meals.  We usually recommend 6 small meals per day instead of the traditional 3 larger meals.  It is important to stay hydrated by drinking plenty of liquids.  Liquid supplements such as Boost, Ensure, or Carnation Instant Breakfast are often helpful as meal replacements or during flares of the disorder.  Strict blood sugar control is needed to help gastric function.  Close monitoring and follow up by the primary care physician or endocrinologist is helpful.

Patients with moderate symptoms that do not respond to the above measures are often given a trial of either Reglan (metaclopramide) or Erythromycin to stimulate the stomach to empty. Reglan is a well known anti-nausea medication that can reduce nausea symptoms and may also stimulate contraction of the stomach and small intestine.  There are some potentially serious neurologic side effects of this medication and it should only be prescribed if the lifestyle changes are not effective.  An alternative to Reglan is an antibiotic called Erythromycin which also increases the emptying rate of the stomach in some patients and has less potential side effects.

For patients with severe gastroparesis that is refractory to the above treatment who are having persistent issues with pain, nausea, dehydration, and weight loss, there is the possibility of having a gastric electrical stimulator placed.  These function similar to a heart pacemaker and are surgically placed in the abdomen with electrical leads implanted into the stomach wall.  Results of the effectiveness of these devices are mixed but some patients report significant improvement in symptoms after the device is placed.

There are additional treatments that are available including placement of feeding tubes to bypass the stomach, surgery to bypass the stomach, and injection of botox into the pyloric sphincter to assist with passage of food out of the stomach.  Determination of the appropriate treatment and/or referral to another specialist should be done by a gastroenterologist after thorough work up.

DIARRHEA, CONSTIPATION, AND FECAL
INCONTINENCE
Dysfunction of the bowel due to diabetes is called intestinal enteropathy.  It can cause symptoms such as diarrhea, constipation, and even fecal incontinence.  Other than strict blood sugar control, the treatment is mostly symptomatic and is gauged to prevent additional problems such as dehydration.

Treatment of diarrhea includes good nutrition and proper fluid intake.  Removing medications that may promote diarrhea is also important.  Anti-diarrheals are often helpful but should be used with caution and under the direction of a physician due to potential for side effects.

Constipation is very common in diabetic patients.  This is again due to poor GI nervous system function that is effected by the diabetes/elevated blood sugars.  Increased physical activity, a diet high in fiber, and laxatives are usually effective.

Fecal incontinence is much more rare but can be caused by poor internal rectal sphincter tone – also a neurologic issue.  Drug related causes such as use of metformin must be considered.  There are some new treatments available for fecal incontinence using neural stimulators to increase rectal tone.  This requires referral to a specialist for evaluation of such a device.

NON-ALCOHOLIC FATTY LIVER DISEASE
Infiltration of fatty deposits in the liver is called fatty liver disease. It is common in persons who are heavy alcohol users but is also commonly found in diabetics, especially those with type 2 diabetes.  The disorder is usually diagnosed after routine labs indicate an elevation in liver function tests.  An ultrasound of the liver is used to confirm the diagnosis.  The fatty deposits can lead to inflammation and fibrosis.  Very rarely it can lead to cirrhosis.  Treatment consists of tight glucose control, low fat diet, weight loos, and cessation of alcohol use.  Close monitoring of hemoglobin A1C is used to follow average blood sugar levels over long periods of time. Your primary doctor will often refer you to a gastroenterologist for evaluation, further testing, and follow-up of this disorder.

SUMMARY
Diabetes has become a prolific disease in the United States. It results in numerous other medical comorbities.  Many of these include problems with the GI tract and may include gastroparesis, diarrhea, constipation, fecal incontinence, and fatty liver disease.  As you have read, the mainstay of treatment is very close management of blood sugar levels. Additional evaluation and treatment for specific symptomatology is done by specialists including gastroenterologists. If you are experiencing these additional sequelae of diabetes then your primary physician may consider referring you to a specialist.

Information obtained from:
Amer Shakil, MD, Robert J. Church, MD, and Shobha S. Rao, MD.  Am Fm Physician, 2008 Jun15;77(12):1697-1702.