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Digestion Update
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Gastrointestinal problems may be associated with diabetes-related nerve damage.
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By Kalia Doner
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Diabetes Focus Fourth Quarter 2005
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Chronically uncontrolled blood sugar levels can wreak havoc on all parts of your body, including nerve functions. Sixty to seventy percent of those who have had diabetes for 25 years or more report some symptoms of what is called diabetic neuropathy. This complication appears to be more common in people who are overweight, have elevated cholesterol and high blood pressure, and are 40 or older—as well as in people who have problems controlling blood glucose levels.
Neuropathy most commonly affects the arms and legs, but for around half of those who have diabetes, the digestive system is the affected area. The result is gastroparesis, or delayed gastric emptying, a disorder in which the stomach takes too long to empty its contents.
To make matters worse, once gastroparesis sets in, abnormal food digestion can make blood glucose levels fluctuate widely.
Researchers are studying the effect of glucose on nerves to find out exactly how prolonged exposure to high blood glucose levels causes neuropathy. They suspect that the high levels damage the blood vessels that carry oxygen and nutrients to the nerves as well as trigger chemical changes in the nerves themselves. Other possible triggers for these changes include autoimmune factors that cause inflammation in nerves and lifestyle habits such as smoking or alcohol use.
Whatever the cause, the result is that nerves to the stomach are damaged or stop working. Particularly vulnerable is the so-called vagus nerve, which is the master switch for the passage of food through the stomach and intestines. If the vagus nerve is damaged, the muscles of the stomach and intestines don’t work correctly and passage of food through the system is slowed down or stopped altogether.
Signs and symptoms can range from mild to severe and include heartburn, nausea, vomiting undigested food, an early feeling of fullness when eating, weight loss, abdominal bloating, erratic blood glucose levels, lack of appetite, gastroesophageal reflux and spasms of the stomach wall.
In addition to these problems, gastroparesis can lead to an overgrowth of intestinal bacteria associated with the fermentation of food. Food can also become compacted into hard masses called bezoars, which can lead to nausea and
vomiting. Bezoars can be dangerous if they block the passage of food into the small intestine.
If you suspect you have gastroparesis, see your doctor, who may use one or more of these tests to make a diagnosis:
• Barium X-ray. Following special instructions from your diabetes
doctor, you fast for 12 hours before drinking a liquid that coats the inside of the stomach, as well as any food still in it—the presence of which indicates slowed emptying.
• Barium beefsteak meal. You eat a barium-laced meal so that the radiologist can “watch” your stomach as it digests the food. Because people with diabetes-related gastroparesis often digest liquid normally, this test may detect emptying problems that do not show up on the liquid barium X-ray.
• Radioisotope gastric-emptying scan. Food that contains a safe dose of a radioactive substance is ingested. A scanning machine then allows the doctor to watch the motion of food through your stomach. Gastroparesis is diagnosed if more than half of the food remains in the stomach after two hours.
• Gastric manometry. A doctor passes a thin tube down your throat into your stomach to measure electrical and muscular activity as you digest food and liquid.
• Blood tests. The doctor may
also order lab tests to check blood counts and measure chemical and electrolyte levels.
Getting glucose levels back under control is job number one when it comes to treating gastroparesis, since continued lack of control only makes the complications, well, more complicated. Your doctor may suggest a combination of insulin, oral medications, dietary changes and, in severe cases, a feeding tube and intravenous feeding. A feeding tube puts nutrients and medication directly into the small intestine, bypassing the stomach and large intestine. IV feeding is usually a temporary way to get you through a difficult spell of gastroparesis. Unfortunately, most treatments do not cure gastroparesis; they simply ease the symptoms. Here’s a look at some of the approaches.
• Insulin therapy. To regain control of your blood glucose levels, your doctor may advise you to start taking insulin or to take it more frequently.
• Medications. Metoclopramide reduces nausea and vomiting and stimulates stomach muscle contractions to help move food through the stomach. The antibiotic erythromycin also increases contractions. Domperidone is not approved in the U.S., although this drug is used elsewhere in the world to treat gastroparesis. In 2004, the FDA issued an alert expressing concern about reports of cardiac arrhythmia, cardiac arrest and sudden death in patients receiving an intravenous form. In several countries where the oral form is still sold, labels warn against its use by breast-feeding women. But in May 2005 the FDA issued a release suggesting doctors request authorization to prescribe it as an investigational drug. This information is available at the Food and Drug Administration Web site: http://www.fda.gov/cder/news/domperidone.htm.
• Other medications. An antiemetic can help with nausea and vomiting. Antibiotics will clear up bacterial infections. If you have a bezoar, the doctor may use an endoscope to inject medication that will dissolve it.
The burning and pain that accompany heartburn are always unpleasant, but when these symptoms crop up more than two or three times a week or wake you from a sound sleep, they may signal a more serious condition that’s known as gastro-esophageal reflux disease (GERD).
GERD happens when the stomach’s contents regurgitate into the esophagus, resulting in irritation and, often, uncomfortable burning sensations behind the breastbone. GERD can sometimes be treated with a few smart lifestyle changes, such as avoiding trigger foods and raising the head of the bed. Yet “many patients require prescription medications,” according to Jack A. DiPalma, M.D., director of the division of gastroenterology at the University of South Alabama College of Medicine in Mobile. So, talk to your doctor if you have frequent heartburn and take steps to cool the fiery discomfort.
You can’t give yourself an ulcer by worrying, although stress and adventurous eating can exacerbate symptoms such as burning or achy pain in the gut. Two thirds of ulcers are caused by an infection with a bacteria called H. pylori; they can also be caused by anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen. You have a greater risk of developing an ulcer if you drink alcohol, smoke, are 50 or older, or have a family history of ulcers.
An ulcer is an irritation or sore in the lining of the stomach or duodenum (the first part of the small intestine), says Brian Lacy, M.D., Ph.D., gastroenterologist at the Dartmouth-Hitchcock Medical Center in Lebanon, NH. Typically, eating eases the pain. Aside from relieving symptoms, treatments aim to prevent the ulcer from perforating the stomach wall or breaking a blood vessel. The first step is to determine whether H. pylori is to blame. If so, your doctor will prescribe antibiotics. Doctors also rely on drugs that neutralize the stomach’s acid, such as antacids and proton pump inhibitors, allowing the ulcer to heal.
If NSAIDs are the problem, you should explore other treatment options with your doctor. “There’s a trade-off,” says Dr. Lacy. “But it may be possible to lower the dose of the NSAID or continue it while also taking a proton pump inhibitor every day to minimize the impact.” In some cases, surgery may be needed to remove the ulcer.
Dietary tweaks may ease gastroparesis symptoms. Doctors often suggest eating six small meals a day. Several liquid meals a day may also be helpful to stabilize blood glucose levels and ease symptoms. Try reducing fat intake, since it slows digestion. Avoid high-fiber foods that cannot be digested.
For complete information on diabetic neuropathy visit the National Diabetes Information Clearinghouse at http://diabetes.niddk.nih.gov/dm/pubs/neuropathies/, or write them for their publications at NDIC, 1 Information Way, Bethesda, MD 20892–3560. Email requests to ndic@info.niddk.nih.gov. The National Digestive Diseases Information Clearinghouse is at 2 Information Way, Bethesda, MD 20892–3570; www.niddk.nih.gov/health/digest/nddic.htm
The National Heartburn Alliance suggests these techniques to help you keep heartburn in check.
• Enough is enough. Avoid overeating and opt for smaller portions. Too much food at one time can put extra pressure on the lower esophageal sphincter (LES) and boost your chances of heartburn.
• Just say no. If certain foods trigger heartburn, avoid them, no matter how tempting they look and smell. Common troublemakers include high-fat items, chocolate, citrus products (lemons, limes, oranges and grapefruit), peppermint and tomato-based products.
• No-snack zone. Give up on those visits to the fridge for midnight snacks.
• Sip ‘n’ slide. Drinks that are alcoholic, caffeinated and/or carbonated can cause heartburn. How about slowly sipping a cool glass of water instead?
• Fat-less. Make your favorite recipes with a bit less fat. Broil, don’t fry; use unsaturated fats, not butter.
• Waist not. Avoid tight-waisted outfits that can make heartburn even worse.
• Sweat it! Add exercise to your daily schedule.
• Breathe deeply. Stress can make heartburn worse, so take the time to do stress-reducing activities like yoga.
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