Diabetes Mellitus: Management of Gastrointestinal Complications

 

Gastrointestinal disorders are common complications of diabetes mellitus and include gastroparesis, nonalcoholic fatty liver disease, gastroesophageal reflux disease, and chronic diarrhea. Symptoms of gastroparesis include early satiety, postprandial fullness, nausea, vomiting of undigested food, bloating, and abdominal pain. Gastroparesis is diagnosed based on clinical symptoms and a delay in gastric emptying in the absence of mechanical obstruction. Gastric emptying scintigraphy is the preferred diagnostic test. Treatment involves glucose control, dietary changes, and prokinetic medications when needed. Nonalcoholic fatty liver disease and its more severe variant, nonalcoholic steatohepatitis, are becoming increasingly prevalent in persons with diabetes. Screening for nonalcoholic fatty liver disease is not recommended, and most cases are diagnosed when steatosis is found incidentally on imaging or from liver function testing followed by diagnostic ultrasonography. Liver biopsy is the preferred diagnostic test for nonalcoholic steatohepatitis. Clinical scoring systems are being developed that, when used in conjunction with less invasive imaging, can more accurately predict which patients have severe fibrosis requiring biopsy. Treatment of nonalcoholic fatty liver disease involves weight loss and improved glycemic control; no medications have been approved for treatment of this condition. Diabetes is also a risk factor for gastroesophageal reflux disease. Patients may be asymptomatic or present with atypical symptoms, including globus sensation and dysphagia. Diabetes also may exacerbate hepatitis C and pancreatitis, resulting in more severe complications. Glycemic control improves or reverses most gastrointestinal complications of diabetes.

Gastrointestinal (GI) disorders are common complications of diabetes mellitus. These complications typically involve dysmotility as a result of hyperglycemia.1 GI symptoms of diabetes are typically not related to the duration or type of diabetes, but may be influenced by the degree of glycemic control maintained by the patient.1 Additionally, these symptoms may be blunted in these patients because of neuropathy.2 GI symptoms of diabetes tend to be preventable, controllable, and sometimes reversible with tighter glycemic control.3

WHAT IS NEW ON THIS TOPIC: GASTROINTESTINAL COMPLICATIONS OF DIABETES MELLITUS

Patients with diabetes mellitus and gastroesophageal reflux disease are more likely to present with atypical symptoms, such as dysphagia or globus sensation. These patients are approximately twice as likely to develop esophageal dysplasia as those without diabetes.

Patients with diabetes and hepatitis C virus infection are more likely to develop severe liver-related complications, including fibrosis and hepatocellular carcinoma.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

In patients with suspected diabetic gastroparesis, laboratory testing and imaging should be performed to rule out other possible causes of symptoms.

C

5

Gastric emptying scintigraphy after a solid meal is the preferred confirmatory test for gastroparesis.

C

3, 5

Metoclopramide (Reglan) is the first-line treatment for symptoms of gastroparesis.

B

3, 5, 14

Liver ultrasonography is more sensitive than hepatic function testing for the diagnosis of nonalcoholic fatty liver disease.

C

19, 23

Lifestyle modifications are the first-line treatment for nonalcoholic fatty liver disease.

C

19, 23

Limiting meal size may be effective for managing symptoms of diabetic esophageal dysmotility.

C

3


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

In patients with suspected diabetic gastroparesis, laboratory testing and imaging should be performed to rule out other possible causes of symptoms.

C

5

Gastric emptying scintigraphy after a solid meal is the preferred confirmatory test for gastroparesis.

C

3, 5

Metoclopramide (Reglan) is the first-line treatment for symptoms of gastroparesis.

B

3, 5, 14

Liver ultrasonography is more sensitive than hepatic function testing for the diagnosis of nonalcoholic fatty liver disease.

C

19, 23

Lifestyle modifications are the first-line treatment for nonalcoholic fatty liver disease.

C

19, 23

Limiting meal size may be effective for managing symptoms of diabetic esophageal dysmotility.

C

3


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Gastroparesis

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The Authors

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BETH CAREYVA, MD, is an assistant professor in the Department of Family Medicine at Lehigh Valley Health Network/University of South Florida Morsani School of Medicine, Allentown, Pa....

BRIAN STELLO, MD, is vice chair of quality and research in the Department of Family Medicine at Lehigh Valley Health Network.

Author disclosure: No relevant financial affiliations.

Address correspondence to Beth Careyva, MD, Lehigh Valley Health Network, 707 Hamilton St., One City Center, 8th Floor, Allentown, PA 18101 (e-mail: beth_a.careyva@lvhn.org). Reprints are not available from the authors.

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