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Treating Gastroparesis

by Kathryn Feigenbaum, RN, MSN, CDE

Although the term gastroparesis may be new to some, the symptoms of this ailment, in which the stomach’s ability to move food into the small intestine is impaired, can be all too familiar, as up to 50% of people with diabetes will develop gastroparesis. The slow stomach emptying characteristic of this condition can cause nausea, vomiting, a feeling of fullness after eating a small amount of food, bloating, discomfort in the upper abdomen, and a lack of appetite. These symptoms can also be accompanied by erratic blood glucose levels, requiring frequent blood glucose checks and injections of insulin.

Symptoms and complications
The most common cause of gastroparesis is damage to the nerve fibers that control the movements of the stomach, branches of a major nerve known as the vagus nerve. The exact cause of the nerve damage is not completely understood, but the most widely accepted theory is that insulin deficiency, high blood glucose levels, or both gradually damage the vagus nerve.

Symptoms associated with gastroparesis include heartburn, reflux of food and liquids into the esophagus, difficulty swallowing, hypoglycemia (low blood glucose) after a meal followed by high blood glucose, constipation alternating with diarrhea, and weight loss. Other consequences and complications include the erratic absorption of medicines taken by mouth, foul breath, dehydration, electrolyte imbalance (electrolytes include salts such as sodium and potassium), and potentially even coma and death.

Gastroparesis can be diagnosed by special studies that evaluate how well the stomach and small intestine are digesting food.

At times, the symptoms of gastroparesis may improve or even disappear. However, the actual delay in stomach emptying time does not seem to correlate very well with the symptoms a person experiences. Additionally, the severity of nerve damage does not match the intensity of the symptoms.

Some people with gastroparesis develop bacterial infections in their stomach or small intestine, and others form a mass of undigested food in the stomach called a bezoar. This retained undigested material can worsen a person’s nausea and vomiting and can sometimes even develop into a complete blockage between the stomach and the small intestine.

Treatments for bezoars may include taking papaya juice or an enzyme known as cellulase orally or via injection to aid digestion. More serious bezoars may require the placement of a tube through the nose into the stomach so that the stomach can be flushed with Coca-Cola or a medicine called acetylcysteine, both of which can help dissolve the mass. Sometimes the undigested material can be broken up and taken out through the mouth using special equipment or through an incision into the stomach. Following any type of bezoar treatment, people must typically stick to a liquid diet for several months to help minimize the accumulation of undigested material in the stomach.

Managing blood glucose and nutrition
Having to follow a liquid diet for a prolonged period can be difficult for some people. However, individual preferences and tastes can be incorporated into the diet to make meals more palatable. Special consideration is needed to make sure that required nutrients, vitamins, minerals, and electrolytes are included in the diet. For example, people with gastroparesis are sometimes deficient in vitamins and minerals such as vitamin B12, vitamin D, and iron, and may therefore need supplements containing these micronutrients. Stomach irritants such as nicotine and caffeine should be avoided.

It’s also important for a person to take in enough calories and nutrients to maintain his body weight. Meals should have a low fat and fiber content and be small in volume. Daily consumption may therefore be divided into six small meals taken throughout the day. Liquids and solid foods that have been pureed in a blender are encouraged. Some examples of recipes for liquid meals can be found in “Recipes for a Liquid Diet.”

All people with gastroparesis are advised to monitor their blood glucose frequently. Intensive blood glucose control that keeps levels stable and as close to normal as possible appears to reduce the severity of gastroparesis symptoms. High blood glucose, on the other hand, can worsen the slow movement of food through the gastrointestinal tract. A continuous glucose monitoring system, which uses a sensor to measure glucose levels in fluid under the skin as often as every few minutes, can be a useful tool for tracking trends in glucose levels.

Checking blood glucose levels after meals is especially important to determine whether either food intake or the timing or size of insulin doses needs to be adjusted to maintain blood glucose within goal range. Some people who use rapid-acting insulin such as lispro (brand name Humalog), aspart (NovoLog), or glulisine (Apidra) administer their injection after they’ve finished eating a meal so they can better match the timing of food absorption. People who use an insulin pump can use the extended bolus or square-wave bolus features, which spread the delivery of an insulin dose over a selected period of time. A person’s health-care provider can assist with determining the percentage of insulin to be delayed and the duration of the bolus infusion. Oral diabetes medicines may also be considered by the health-care team for use alone or together with insulin.

Medical treatments
In addition to blood glucose control, certain drugs or other treatments can also help reduce the symptoms of gastroparesis.

Total parenteral nutrition. People who do not improve with medicines and who cannot get the proper nutrition through eating are often hospitalized so they can benefit from intravenous fluids that provide calories, minerals, vitamins, and nutrients, a type of treatment known as total parenteral nutrition. A tube may be threaded through the person’s nose into the stomach to drain fluid and air.

Enteral nutrition. An alternative to total parenteral nutrition is enteral nutrition, in which the necessary medicines and nutrients are provided directly into the gastrointestinal tract via a tube placed into the stomach or small intestine. The tube can also be used to drain liquid and air from the gastrointestinal tract. Both total parenteral nutrition and enteral nutrition treatments may last for a long period of time, depending on when the stomach is able to handle solid food again.

Gastric electrical stimulation. When a person has not responded to drug treatment or other conservative treatments such as changing the amounts or types of food in the diet, gastric electrical stimulation may be tried. This technique uses mild electrical pulses produced by a gastric pacemaker to stimulate the nerves of the lower stomach. These pulses are transmitted by means of electrodes that are surgically placed in the wall of the lower stomach. The settings of the device can be adjusted with an external programming system based on individual circumstances, such as the number of times a person becomes nauseated and vomits. Gastric electrical stimulation can be temporarily stopped by the health-care provider if a person needs to undergo magnetic resonance imaging (MRI), radiation therapy, defibrillation, or other medical procedures. This therapy may be used in conjunction with specific medicines to decrease gastroparesis symptoms.

Potential side effects, though rare, may include infection, unwanted movement of the device, a hole in gastrointestinal tract, an undesirable change in stimulation (due to movement of the electrodes, for example), bleeding, bruising, pain at the site of an electrode, allergic reaction, pneumonia, and dehydration.

Botox. Injections of Botulinum toxin (Botox) at the connection between the stomach and small intestine have recently been used to increase the emptying of food from the stomach. This method works because the muscle that controls the opening of the stomach into the small intestine, when injected with Botox, becomes paralyzed by the Botox and allows food to pass through continuously.

Experimental treatments. One treatment for gastroparesis that is currently under investigation is the use of nitric oxide to normalize the movements of the gastrointestinal tract. Acupressure therapy is also being considered as a way to relieve the nausea, vomiting, and bloating that can be caused by gastroparesis.

Getting help
People who have gastroparesis should speak to their health-care team about creating a treatment plan that best fits their individual needs. Keeping a logbook with records of blood glucose levels, meal times and amounts, symptoms, exercise times and amounts, and medicine doses and schedules can help the health-care team make adjustments in the medical plan and also help the person with gastroparesis make daily decisions about his insulin and carbohydrate needs. Coping with gastroparesis can be frustrating, but it is important to remember that blood glucose monitoring, a balanced diet, and regular exercise can all help to treat this condition.

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Also in this article:
Recipes for a Liquid Diet

 

 

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