Diabetic Gastroparesis. Evan M. Klass, MD, FACP February 16, 2017

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1 Diabetic Gastroparesis Evan M. Klass, MD, FACP February 16, 2017

2 Scope of the problem The disorder can affect any part of the GI tract Although 10-20% of the general population suffer from functional GI disorders, patients with Type 1 and Type 2 DM have more sx And the worse the sx the worse the associated Diabetes control Patients with Type 1 are more likely to have gastroparesis GI function tests are not always definitive Gastric emptying studies do not correlate with sx of nausea and vomiting

3 Pathophysiology A manifestation of autonomic neuropathy- others of which include orthostatic hypotension, abnormal sweating Generally occurs following other microvascular complications Disordered gastric or bowel contraction related to loss of neuronal mass- denervation

4 Clinical presentation Early satiety Prolonged fullness Bloating Nausea/vomiting- often of chewed but undigested food Abdominal pain- but less common in DM than in non-diabetic gastroparesis Physical examination is no particularly revealing Remember the succussion splash??

5 Diagnosis 1) remember to think of it! A cause of unexplained glycemic excursions/ with both lows and highs related to erratic gastric emptying 2) exclude other diagnoses/ often necessitates endoscopy 3) technetium/egg gastric emptying study 4) capsule enteroscopy 5) gastric electrical activity study- don t try this in your office

6 Treatment Very challenging because improving glycemic control is imperative! Avoid oral agents because of uncertain absorption and because even patients with Type 2 have advanced disease Basal/bolus regimens either pump or injection delivered Bolus should be administered post-prandially Regular insulin may be preferable BUT: the most important component of treatment is dietary!

7 Nutritional therapeutic approach

8 Pharmacotherapy Prokinetics Metoclopramide 5-20 mg TID ac Erythromycin QID Domperidone- through Canada or through FDA by IND Anti-nausea Ondansetron 4-8 mg BID Anxiolytics Lorazepam mg QID Alprazolam mg TID

9 Invasive therapies Gastric electrical stimulation Gastric pacing Botulinum toxin injection Pyloric dilation

10 Nutrition and Gastroparesis February 16, 2017 Karmella Thomas, RDN, LD, CDE

11 Nutrition s role and goals Support glycemic control Hyperglycemia can slow the rate of gastric emptying Food modifications Small, frequent meals, low-fat, low-fiber, liquid meals Jejeunostomy enteral feedings (severe cases) Adjustments in bolus insulin Consideration for taking insulin after eating vs before Exercise Postprandial exercise (walking) to increase solid-meal gastric emptying

12 Controlled nutrition trails? No controlled trails of varying food modifications for treatment of gastroparesis is currently available. Nutrition recommendations are based on professional judgment and clinical practice as well as logical interpretation of gastric physiology

13 Common food modifications Small, frequent meals that are nutritionally balanced Concerns are early satiety and bloating that can reduce quantity of food and frequency of intake risk of compromised nutritional status Consumption of more liquid calories later in the day with solids early in the morning Liquid meals or blenderized meals late in the day

14 Common food modifications Chew foods well Sit up during the meal and for at least 1-2 hours after each meal Reduced fat diet Fat can inhibit gastric emptying in a solid meal (less in liquid form) Lower fiber content Fibrous vegetables and fruits (oranges and broccoli) Increased risk of blockage from undigested foods

15 Recommended Foods Milk Instant breakfast Milkshakes and smoothies Yogurt Puddings and custard Pureed foods Soup

16 Common nutrition diagnoses Inadequate vitamin intake Inadequate mineral intake Impaired nutrient utilization Excessive fiber intake Altered gastrointestinal function Unintended weight loss

17 Considerations Supplements for possible magnesium, iron and ferritin, vitamin B-12, 25-hydroxyl vitamin D chewable or liquid versions Enteral or parenteral nutrition support Gastric failure or inability to maintain weight via oral route Unintentional weight loss, especially in 6 month time period High Risk: BMI under 18.5 kg/m2 or BMI kg/m2 and 5-10% weight loss Medium Risk: BMI kg/m2 and less than 5% weight loss or BMI above 20 kg/m2 and weight loss of 5-10%

18 Sample Menu Breakfast Morning Snack Lunch Afternoon snack Evening Meal Evening Snack 1 c cooked oatmeal (2 carbohydrate servings) ½ c non fat milk (1/2 carbohydrate serving) ½ cup orange juice (1 carbohydrate serving) 1 scrambled egg 1 packet instant breakfast mix (1.5 carbohydrate serving) 1 cup skim milk (1 carbohydrate serving) 1 cup vegetable soup (1 carbohydrate) 6 soda crackers (1 carbohydrate) ½ c applesauce (1 carbohydrate) ½ c nonfat milk (1/2 carbohydrate) 6 oz plain yogurt (1 carbohydrate) 1 small banana (1 carbohydrate) 3 oz baked fish ½ cup mashed potatoes (1 carbohydrate) and 1 tsp margarine 1 c cooked carrots (1 carbohydrate) ½ cup skim milk (1 carbohydrate) ½ c canned fruit, in juice (1 carbohydrate) 1 cup pudding (2 carbohydrates)