DIABETIC GASTROPARESIS


I. Clinical aspects

  1. Delayed gastric emptying, not related to diabetic nephropathy
  2. Nausea, esp. post-prandial
  3. Vomiting, esp. undigested food and bezoars
  4. Epigastric pain, bloating, early satiety, anorexia
  5. Unpredictable blood glucose fluctuations
  6. May be worse during periods of hyperglycemia, but relationship between duration/severity of DM and gastroparesis is not established
  7. Prevalence is about 33% of diabetics

II. Diagnosis: radionucleide test meal

III. Treatment

  1. Non-pharmacologic: avoid high-fat, high-fiber meals. Liquid, iso-osmotic meals have been used in severe cases.
  2. Prokinetic agents: work well, though poor correlation between symptoms and degree of impairment of gastric emptying!
  1. Metoclopramide 10mg PO QID
  1. Drug of choice; best evidence for positive effect
  2. Works as dopamine antagonist and promotes Ach secretion in GI sm. mm. cells
  3. Contraindications: GI bleed, obstruction, h/o epilepsy, parkinson's
  4. Side f/x: drowsiness, extrapyramidal sx, amenorrhea, galactorrhea
  5. Unclear whether it's effective long-term
  1. Cisapride 10-20mg TID
  1. Good alternative to metoclopramide
  2. Increases Ach release from myenteric plexus cells
  3. +/- change in symptoms in well-designed studies
  4. Can cause diarrhea, borborygmi
  5. Probably does work long-term
  1. Domperidone 10 QID - 20 TID
  1. A dopamine antagonist
  2. Not clearly better than placebo in double-blind trials
  3. Side f/x include dry mouth but no neuro f/x
  1. Erythromycin 250 TID
  1. Acts as a "motilin" agonist
  2. Analogues without antibiotic effects may be promising
  3. No studies of sx improvement as of 1990? Improves gastric emptying c/w placebo (NEJM 322:1028, 1990)
  1. Renzapride
  1. A dopamine agonist
  2. Only one study as of 1993, showing decreased gastric emptying time; sx not explored
  1. Gastric pacing in refractory cases, e.g. pts requiring tube feeds