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DKA symptoms and diabetic gastroparesis

DKA symptoms and diabetic gastroparesis

From a pathophysiological perspective, it is tastroparesis to DKA symptoms and diabetic gastroparesis applying concepts emanating Game fuel replenisher animal models of diabetic symphoms and from other complications of DM in humans e. As reviewed elsewhere 90acute hyperglycemia delayed GE in healthy people In the pivotal study, the GE time measured by this capsule and scintigraphy were correlated

DKA symptoms and diabetic gastroparesis -

The intensity of symptoms can also be influenced by a number of factors, which include degree of nerve damage, glycaemic control, diet and compliance with therapy.

Unfortunately, even in more modern times, gastroparesis is a relatively rare condition and healthcare professionals often fail to make an accurate diagnosis, even when individuals present with the classical symptoms.

Particularly in the early stages, it can be difficult to distinguish gastroparesis from irritable bowel syndrome, given that certain features such as bloating, colicky abdominal pain and periods of exacerbation and remission are common features of both conditions NHS Choices, Equally, individuals who have classical indicators of gastroparesis are unlikely to relate them to a complication associated with their diabetes.

Pathology Gastric emptying can be normal, accelerated or retarded in individuals with diabetes Horowitz et al, ; Kong et al, However, people with gastroparesis will have multiple motor and sensory abnormalities of upper gut function. These anomalies include antral hypomotility, altered intragastric distribution of ingested food, abnormal intestinal contractions, increased fundic compliance and abnormal gastric sensation.

Gastroparesis impairs emptying of the stomach, which will lead to gastric dilatation and vomiting. Gastric stasis is a common feature of gastroparesis Stacher, ; Stacher et al, , and is thought to be due to vagal denervation of the stomach and smooth muscle loss Jackson et al, Studies have demonstrated that there is loss of myelinated and unmyelinated fibre in the vagus nerve in people with gastroparesis Malagelada, Vagal nerve degeneration does not normally cause gut smooth muscle deterioration and is possibly related to glucose-mediated smooth muscle damage Watkins, Impact of blood glucose concentrations on gut function Hyperglycaemia has a profound effect on gut function and has been found to slow gastric emptying, reduce post-prandial antral contractions and alter proximal stomach perception Samson et al, ; Rayner et al a.

All individuals with insulin-requiring diabetes need to co-ordinate the absorption of carbohydrate with insulin delivery. Yet, it is evident, both in healthy individuals and those with diabetes, that acute changes in blood glucose concentrations will have a substantial and reversible effect on gastric motility Rayner et al, Gastric emptying and postprandial antral contractions of the stomach are reduced during hyperglycaemia when compared to euglycaemia and increased during periods of hypoglycaemia Samson et al, There is also some evidence to suggest that raised blood glucose levels may cause reversible vagal efferent dysfunction De Boer et al, Diagnosis Diagnosis of gastroparesis is usually made on clinical history and confirmed following the results of gastric emptying studies and a gastroscopy.

A gastroscopy should also be performed to rule out any obstruction or other condition that may be impacting on the symptoms Murray and Emmanuel, Table 1 lists some common differential diagnoses. Gastric emptying studies Gastric emptying studies measure the rate at which food leaves the stomach to pass into the small intestine and are considered the gold standard for measuring gastric motility Maurer, The procedure involves the individual swallowing a small quantity of a radioactive substance that has been mixed with food.

Then for a period of up to three hours, a radiation scanner is used to measure the level of radioactivity in the stomach.

There are some standardisation factors to consider when interpreting the results of the gastric emptying studies. These include any differences in the foods used during the test, the amount of food eaten, positioning and the use of pro-kinetic agents in the period leading up to the test Abell et al, ; Maurer, Pro-kinetic agents should be discontinued at least 48 hours before gastric emptying studies Camilleri et al Although the levels of radioactivity during the procedure are very low and do not cause any side effects, women who are pregnant or breast-feeding should not participate, as there is a small risk of harm to the fetus or baby.

Prognosis The long-term outlook for people with symptomatic gastroparesis and multiple complications relating to their diabetes is poor Watkins et al, However, people with abnormal gastric emptying tests who do not necessarily have symptoms have a much better prognosis Kong et al, b.

General principles A diagnosis of gastroparesis presents highly complex management problems for any healthcare professional to manage successfully in isolation.

Support will be needed from a multidisciplinary team that can work in partnership with each other and the individual with gastroparesis. This seamless holistic approach will help to optimise outcomes.

A key treatment goal is that the symptoms associated with gastroparesis are minimised and adequate psychological support is provided by the professional team providing care.

In keeping with all people with diabetes, the individual with gastroparesis will require intensive education around their diagnosis and treatment plan so that informed choices regarding self-care management strategies can be made.

Glycaemic control For individuals with gastroparesis, glycaemic control should be optimised as hyperglycaemia delays gastric emptying Rayner et al, The absorption of glucose from food will be erratic due to the variability in gastric emptying.

The usual outcome of this is glycaemic instability, including hypoglycaemia. Pramming found that the vast majority of individuals with insulin-requiring diabetes fear hypoglycaemic episodes, and in an attempt to prevent these events, people with gastroparesis will omit insulin when they feel nauseous or are vomiting.

Unfortunately, if this strategy is used, hyperglycaemia develops and this has a detrimental impact on gastric emptying and the symptoms associated with it Schvarcz et al, Although this practice of omitting insulin is, to some extent, understandable, in the worst-case scenario, this practice of missing doses of insulin could cause the individual to develop the diabetic ketoacidosis.

Matching insulin to glucose release in individuals with gastroparesis is very difficult, despite the use of optimised insulin regimens.

The action of the prandial insulin can be delayed to match the retarded glucose release, by taking it after eating. The time interval from ingestion to injection can be based on analysis of the gastric emptying studies and then be altered according to the response on glycaemic trends.

Some clinicians advocate the use of soluble insulin taken with food to cover the postprandial rise in glucose. This is because soluble insulin is not active for approximately 20—30 minutes after injection and it will have a longer action time, when compared to a rapid-acting analogue.

There has also been significant success using continuous subcutaneous insulin infusions for selective individuals with severe gastroparesis in experienced insulin pump centres Sharma et al, Hypoglycaemia Hypoglycaemia in people with gastroparesis can be prolonged and difficult to treat.

If products such as fluids and starchy foods are used to treat hypoglycaemia, the release of glucose from these products is delayed due to abnormal gastric emptying. In addition, if carbonated products are used, these tend to make an individual with gastroparesis feel nauseous and cause them to vomit.

In our clinical experience, these people should use dextrose tablets or glucose gel as a fast-acting carbohydrate, as these products can be absorbed buccally. Once the blood glucose has risen, a more complex product should be given in liquid or semi-solid form, such as milk or yogurt.

As a back up, it is advisable for all individuals with gastroparesis to be prescribed glucagon injections and a family member should be taught how to inject.

Dietary issues In conjunction with pharmacological therapy, it is vitally important that nutrition health is maintained NHS Choices, Although there are currently no studies confirming the efficacy of dietary manipulation, it is intuitive that foods that slow gastric emptying will worsen gastroparesis in symptomatic periods NHS Choices, Any individual with gastroparesis needs to work closely with a dietitian who is familiar with the condition and they should be encouraged to follow the dietary principles as suggested by NHS Choices and detailed below:.

Should the individual with gastroparesis develop intractable vomiting then they may require feeding through a percutaneous endoscopic jejunostomy PEJ tube to maintain their nutritional state, which may alleviate the problem until a natural remission of vomiting occurs Gentilcore et al, Initially, the feeds are administered over 24 hours so that a smaller hourly fluid volume can be tolerated Murray and Emmanuel, The continuous feed rate encourages greater predictability of carbohydrate metabolism, which, in turn, leads to a reduction in glycaemic viability.

The individual would also be encouraged to slowly build up their oral intake of diet and fluids. Parenteral feeding would only be considered as a last resort due to the major associated risks, such as line sepsis Murray and Emmanuel, Pro-kinetic therapy Pro-kinetic medication is used to improve gastric emptying by targeting a number of receptors.

These pro-kinetic agents include the dopamine-2 antagonists, metoclopramide and domperidone, which enhance gastric tone and emptying Sturm et al, Erythromycin, a motilin analogue, can also be used as it has a substantial acceleration of gastric emptying Janssens et al, Due to potential side effects it is not advisable to take metoclopramide long term, due to the risk of extrapyramidal effect Joint Formulary Committee, Indeed, recent guidance from the Medicines and Healthcare products Regulatory Agency MHRA; recommends that the use of metoclopramide for adults should be restricted to a maximum of 5 days at a dose no higher than 10 mg three times per day.

Another MHRA alert in highlighted that erythromycin should not be used in combination with domperidone, as there is a risk of causing a prolonged QT interval MHRA, The MHRA have recently recommended that domperidone should only be used to relieve nausea and vomiting, at the lowest effective dose, for the shortest possible duration of time due to the increased risk of cardiac arrhythmias.

It could be argued that the MHRA , , recommendations are unrealistic for individuals with gastroparesis, given that long-term pro-kinetic therapy is usually required for this group of patients. At its best, pro-kinetic therapy has a variable effect on gastroparesis and is not effective at alleviating symptoms in the long term.

With the issue of tachyphylaxis, the practitioner must be prepared to revise the treatment regimen as necessary. A key part of any education programme for an individual with gastroparesis is information regarding their medication needs. In our practice, individuals prone to severe exacerbations of gastroparesis are taught to self-administer an intramuscular injection of metoclopramide, mainly for its pro-kinetic action rather than its antiemetic effect.

This management plan gives the individual a degree of control, so that they have an opportunity to promptly intervene and self-manage their condition, without the need for hospital admission.

If one injection of metoclopramide does not resolve the period of exacerbation, our guidelines instruct the individual to come to hospital. Efficacy of medication can also be detrimentally affected by gastric delay Rayner et al, b.

All medication should be prescribed in suspension or dispersible formulation, given that there is some evidence of greater efficacy of drugs in this form for people with gastroparesis Ehrenpresis et al, Other treatment options If pro-kinetic therapy alone fails to provide adequate relief from gastroparesis-related symptoms, then injections of botulinum toxin around the pylorus under endoscopic guidance can provide temporary relief of symptoms Ezzeddine et al, Despite optimised therapy, some individuals continue with intractable symptoms.

In such individuals, gastric pacemakers have been used in specialist centres. These devices, which use neuro-stimulation to improve gastric emptying, have to be inserted surgically.

Although gastric pacemakers are not considered standard practice, NICE have recently supported the use of gastric pacing in selected individuals attending specialist centres.

However, the report also acknowledges the lack of solid evidence for gastric pacing, the potential side effects and the fact that many individuals do not get any benefit from it as evidence supporting positive outcomes is lacking NICE, Indeed, as highlighted by Abell et al , following insertion of a gastric pacemaker, there is often a poor correlation between gastric emptying and symptom improvement.

Conclusion Gastroparesis is a difficult and complex problem that requires specialist management from diabetes teams who are familiar with this condition, flexible in approach, and alert to the presence of other autonomic issues and complications associated with diabetes. The aim of treatment for individuals with gastroparesis is to improve their symptoms.

Although gastric emptying will stay abnormal, enhanced glycaemic control is the only thing that will consistently have a positive impact on the symptom control of gastroparesis.

Unfortunately, to date, there is no specific therapy that totally addresses these goals. In addition, education for the person with gastroparesis is essential.

The more that an individual understands about their condition and its management, the more likely they are to be pro-active partner in its management. Abell TL, Van Cutsem E, Abrahamsson H et al Gastric electrical stimulation in intractable symptomatic gastroparesis.

Digestion 66 : —12 Abell TL, Camilleri M, Donohoe K, et al Consensus recommendations for gastric emptying scintigraphy. Am J Gastroenterol : 1—11 British Medical Journal Gastroparesis: Differential Diagnoses.

BMJ, Epocrates. Am J Gastroenterol : 18—37 De Boer SY, Masclee AA, Lam WF Effect of hyperglycaemia on gallbladder motility in type 1 insulin-dependent diabetes mellitus.

Diabetologia 37 : 75—81 Diabetes Control and Complications Trial Research Group The effect of intensive treatment of diabetes on the development and progression of long term complications in IDDM. New Engl J Med : —9 Dowling CJ, Kumar S, Boulton AJM et al Severe gasro-perisis diabeticorum in a young patient with insulin dependent diabetes.

BMJ : —11 Ehrenpresis ED, Zaitman D, Nellans H What form of erythromycin should be used to treat gastroparesis? A pharmacokinetic analysis. Aliment Pharmac Ther 12 : —6 Enck P, Frieling T Pathophysiology of diabetic gastroparesis.

Diabetes 46 Suppl 2 : S77—S81 Ezzeddine D, Jit R, Katz N et al Pyloric injection of botulinum toxin for treatment of gastroparesis. Gastrointest Endosc 55 : —3 Feldman M, Schiller LR Disorders of gastrointestinal motility associated with diabetes mellitus.

Ann Intern Med 98 : —84 Geliebter A, Melton PM, McCray RS et al Gastric capacity, gastric emptying, and test-meal intake in normal and bulimic women. Meal and Food Changes Changing your eating habits can help control gastroparesis. Your doctor or dietitian will give you specific instructions, but you may be asked to eat six small meals a day instead of three large ones.

If less food enters the stomach each time you eat, it may not become overly full. Or the doctor or dietitian may suggest that you try several liquid meals a day until your blood glucose levels are stable and the gastroparesis is corrected.

Liquid meals provide all the nutrients found in solid foods, but can pass through the stomach more easily and quickly. The doctor may also recommend that you avoid high-fat and high-fiber foods.

Fat naturally slows digestion—a problem you do not need if you have gastroparesis—and fiber is difficult to digest. Some high-fiber foods like oranges and broccoli contain material that cannot be digested. Avoid these foods because the indigestible part will remain in the stomach too long and possibly form bezoars.

Feeding Tube If other approaches do not work, you may need surgery to insert a feeding tube. The tube, called a jejunostomy tube, is inserted through the skin on your abdomen into the small intestine.

The feeding tube allows you to put nutrients directly into the small intestine, bypassing the stomach altogether. You will receive special liquid food to use with the tube. A jejunostomy is particularly useful when gastroparesis prevents the nutrients and medication necessary to regulate blood glucose levels from reaching the bloodstream.

By avoiding the source of the problem — the stomach — and putting nutrients and medication directly into the small intestine, you ensure that these products are digested and delivered to your bloodstream quickly.

A jejunostomy tube can be temporary and is used only if necessary when gastroparesis is severe. Parenteral Nutrition Parenteral nutrition refers to delivering nutrients directly into the bloodstream, bypassing the digestive system.

The doctor places a thin tube called a catheter in a chest vein, leaving an opening to it outside the skin. For feeding, you attach a bag containing liquid nutrients or medication to the catheter. The fluid enters your bloodstream through the vein. Your doctor will tell you what type of liquid nutrition to use.

This approach is an alternative to the jejunostomy tube and is usually a temporary method to get you through a difficult spell of gastroparesis. Parenteral nutrition is used only when gastroparesis is severe and is not helped by other methods.

The pacemaker is a battery-operated, electronic device that is surgically implanted. It emits mild electrical pulses that stimulate stomach contractions so food is digested and moved from the stomach into the intestines. The electrical stimulation also helps control nausea and vomiting associated with gastroparesis.

The use of botulinum toxin has been shown to improve stomach emptying and the symptoms of gastroparesis by decreasing the prolonged contractions of the muscle between the stomach and the small intestine pyloric sphincter. The toxin is injected into the pyloric sphincter.

Phone: Signs and Symptoms Signs and symptoms of gastroparesis are: heartburn nausea vomiting of undigested food an early feeling of fullness when eating weight loss abdominal bloating erratic blood glucose levels lack of appetite gastroesophageal reflux spasms of the stomach wall These symptoms may be mild or severe, depending on the person.

Complications of Gastroparesis If food lingers too long in the stomach, it can cause problems like bacterial overgrowth from the fermentation of food. After fasting for 12 hours, you will drink a thick liquid called barium, which coats the inside of the stomach, making it show up on the x-ray.

Normally, the stomach will be empty of all food after 12 hours of fasting. If the x-ray shows food in the stomach, gastroparesis is likely. If the x-ray shows an empty stomach but the doctor still suspects that you have delayed emptying, you may need to repeat the test another day.

On any one day, a person with gastroparesis may digest a meal normally, giving a falsely normal test result. If you have diabetes, your doctor may have special instructions about fasting.

Barium beefsteak meal. You will eat a meal that contains barium, thus allowing the radiologist to watch your stomach as it digests the meal.

The amount of time it takes for the barium meal to be digested and leave the stomach gives the doctor an idea of how well the stomach is working.

This test can help detect emptying problems that do not show up on the liquid barium x-ray. In fact, people who have diabetes-related gastroparesis often digest fluid normally, so the barium beefsteak meal test can be more useful.

Radioisotope gastric-emptying scan. You will eat food that contains a radioisotope, a slightly radioactive substance that will show up on the scan. The dose of radiation from the radioisotope is small and not dangerous. After eating, you will lie under a machine that detects the radioisotope and shows an image of the food in the stomach and how quickly it leaves the stomach.

Gastroparesis is diagnosed if more than half of the food remains in the stomach after 2 hours. Gastric manometry. This test measures electrical and muscular activity in the stomach. The doctor passes a thin tube down the throat into the stomach. The measurements show how the stomach is working and whether there is any delay in digestion.

Blood tests. The doctor may also order laboratory tests to check blood counts and to measure chemical and electrolyte levels.

Upper endoscopy. After giving you a sedative, the doctor passes a long, thin tube called an endoscope through the mouth and gently guides it down the esophagus into the stomach.

BMC Endocrine Disorders DKA symptoms and diabetic gastroparesis 23 gastroparfsis, Article number: Cite this article. Ciabetic details. Gastrointestinal GI symptoms are commonly observed in patients DKA symptoms and diabetic gastroparesis nad ketoacidosis DKAwhich usually resolves completely with therapy. However, GI symptoms can persist after DKA resolves, which can pose diagnostic and management challenges for physicians, especially when dealing with an exceptional diagnosis such as cannabinoid hyperemesis syndrome CHS. In this case report, we present a patient with type 1 diabetes who had been treated for DKA 6 times in the past year and was eventually diagnosed with CHS.

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What is Diabetes Ketoacidosis Time-restricted feeding studies condition develops when the DKA symptoms and diabetic gastroparesis can't produce enough duabetic. Insulin plays a DKA symptoms and diabetic gastroparesis gastroparewis in helping sugar syjptoms a major source of energy for muscles and other tissues — enter cells in the body. Without enough insulin, the body begins to break down fat as fuel. This causes a buildup of acids in the bloodstream called ketones. If it's left untreated, the buildup can lead to diabetic ketoacidosis. If you have diabetes or you're at risk of diabetes, learn the warning signs of diabetic ketoacidosis and when to seek emergency care. DKA symptoms and diabetic gastroparesis

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