1. Provided Courtesy of Nutrition411.com Where Health Care Professionals Go for Information Gastroparesis, Diarrhea, Gallbladder Atony, and Thrush: Diabetes and the Gut D-0655 8/12

2. Diabetes and the Gut Gastroparesis Diarrhea Gallbladder Atony Thrush

3. Gastroparesis: Definition The vagus nerve, which generally controls the movement of food through the digestive tract, is damaged The muscles of the stomach and intestines do not work properly The movement of food is slowed or stopped Can occur in either type 1 or type 2 diabe tes

4. Cause of Gastroparesis Chronically high blood-glucose levels: – Causes chemical changes in nerves – Damages the blood vessels that carry oxygen and nutrients to the nerves

5. Symptoms of Gastroparesis Heartburn Nausea (especially in morning) Vomiting undigested food Early satiety Weight loss Abdominal bloating Erratic blood glucose levels Lack of appetite Gastroesophageal reflux

6. Complications of Gastroparesis More difficult to manage blood glucose Bacterial overgrowth in stomach Bezoar formation—may lead to obstruction

7. Diagnosing Gastroparesis Barium X-ray: – Fast for 12 hours and drink barium-containing liquid – If food is still present in stomach, diagnosis is made Barium beefsteak meal: – Eat a meal that contains barium – Time of transit is monitored

8. Diagnosing Gastroparesis (cont’d) Radioisotope gastric-emptying scan: – Eat food that contains radioisotope – Imaging used to see food in stomach and to time transit – Diagnosis if more than half of food remains in stomach after 2 hours Gastric manometry: – Thin tube passed down throat into stomach – Wire in tube measures electrical and muscular activity

9. Keep in Mind Liquids may empty normally from the stomach in spite of severe abnormalities in the ability to empty solid materials from the stomach into the duodenum

10. Treating Gastroparesis Decreased fat and fiber intake Multiple small meals: – Liquid diet sometimes is necessary – Oral nutrition supplements often recommended Smoking cessation Light postprandial exercise, such as walking Changes in insulin type and timing: – Take insulin after meals, instead of before meals – Take insulin more often

11. Treating Gastroparesis (cont’d) Oral medications: – Reglan ® (metoclopramide) Prokinetic that coordinates antral duodenal and pyloric muscle function A powerful, centrally acting antiemetic Can cause Parkinson’s disease-like symptoms Generally well tolerated for 2 – 3 days Benadryl ® can help with relief of side effects

12. Treating Gastroparesis (cont’d) Nonspecific antiemetics, such as Phenergan ® and Compazine ®, often used for symptom relief Intravenous erythromycin: – Binds to motilin receptors on gastrointestinal tract smooth muscle membranes, thereby mimicking motilin’s actions Botox ® injections into pylorus

13. Treating Gastroparesis (cont’d) Relief band: – Wrist device that sends electrical impulses and stimulates the median nerve – Can control nausea when medications are not effective or cannot be used secondary to negative side effects

14. Treating Severe Gastroparesis Jejunostomy (may use only at night): – Percutaneous endoscopic jejunostomy (PEJ) is discouraged because contents will regurgitate into stomach if patient is vomiting frequently Parenteral nutrition: – Generally only used briefly during hospitalization, not on outpatient basis

15. Treating Severe Gastroparesis (cont’d) Gastric neurostimulators activate contraction of smooth muscle or nausea and vomiting control mechanisms Total gastrectomy if intractable weight loss and vomiting in end-stage gastroparesis, if all other options have failed: – Usually patient already has had a partial gastric resection

16. Diabetic Diarrhea People with diabetes mellitus are more likely to suffer chronic diarrhea than the general population Possible causes: – Nerve damage; autonomic neuropathy – Malabsorption of nutrients – Bacterial overgrowth in intestines

17. Bacterial Overgrowth Broad-spectrum antibiotics to decrease bacteria Small bowel intubation sometimes is necessary for diagnosis Breath hydrogen testing and the 14C-D-xylose test may prove helpful

18. Short-term Treatment of Diabetic Diarrhea Imodium ® Pepto-Bismol ® Kaopectate ® Lomotil ®

19. Long-term Treatment of Diabetic Diarrhea Antibiotics such as tetracycline Somatostatin analogs, such as Sandostatin ® Antispasmodics, such as Levsin ®, Bentyl ®, Librax ®, Clindex ® Sometimes trial of pancreatic enzymes Fiber supplementation with bran, Citrucel ®, Metamucil ®, or high-fiber foods

20. Gallbladder Atony People with diabetes mellitus have an increased incidence of gallstones Primarily related to obesity of type 2 diabetes mellitus: – Other possible causes include autonomic neuropathy (bile not released normally and sludge forms) or increased triglycerides, which cause stone formation – Insulin-resistant mice are shown to have increased cholesterol content of the bile, which may lead to stone formation

21. Gallbladder Atony (cont’d) Symptoms of biliary colic include intermittent right upper abdominal pain, jaundice, or pancreatitis Surgery usually only recommended for individuals with symptomatic gallstones

22. Thrush Poor glycemic control Mouth: – Burning and pain with thick white coating of tongue and throat Candida esophagitis: – Can cause intestinal bleeding, heartburn, dysphagia – Will require endoscopy for diagnosis Antifungal medications, such as Mycostatin ®, Nizoral ®, or Diflucan ®

23. Sources American Diabetes Association ®. Gastroparesis. Available at: http://www.diabetes.org/living-with- diabetes/complications/gastroparesis.html. Accessed August 28, 2012. http://www.diabetes.org/living-with- diabetes/complications/gastroparesis.html eMedTV. Diabetic diarrhea. Available at: http://diabetes.emedtv.com/diabetes/diabetic-diarrhea.html. Accessed August 28, 2012. http://diabetes.emedtv.com/diabetes/diabetic-diarrhea.html McCallum RW, George SJ. Gastroparesis. Available at: http://www.oley.org/lifeline/gastro.html. Accessed August 28, 2012. http://www.oley.org/lifeline/gastro.html Stresing D. Gallbladder problems and diabetes. Available at: http://www.everydayhealth.com/gallbladder/gallbladder-problems-and- diabetes.aspx. Accessed August 28, 2012. http://www.everydayhealth.com/gallbladder/gallbladder-problems-and- diabetes.aspx Wolosin JD, Edelman SV. Diabetes and the gastrointestinal tract. Available at: http://journal.diabetes.org/clinicaldiabetes/V18N42000/pg148.htm. Accessed August 28, 2012.http://journal.diabetes.org/clinicaldiabetes/V18N42000/pg148.htm