Revista Médico-Científica "Luz y Vida"

ISSN: 2219-8032
revista_luzyvida@hotmail.com
Universidad Mayor de San Simón
Bolivia

Carpio-Deheza, Gonzalo; Almendras, Mary Cruz

GASTROPARESIA DIABÉTICA: UNA COMPLICACIÓN GASTROINTESTINAL
SUBDIAGNÓSTICADA EN LA NEUROPATÍA DIABÉTICA
Revista Médico-Científica "Luz y Vida", vol. 2, núm. 1, 2011, pp. 46-50
Universidad Mayor de San Simón
Cohabamba, Bolivia

Disponible en: http://www.redalyc.org/articulo.oa?id=325028222009

Rev Méd-Cient “Luz Vida”. 2011;2(1) :46-50

 ISSN 2219-8032

NEURO-ENDOCRINOLOGY
NEURO-ENDOCRINOLOGY
DIABETIC GASTROPARESIA: A GASTROINTESTINAL COMPLICATION
SUBDIAGNOSTIC IN DIABETIC NEUROPATHY
DIABETIC GASTROPARESIS: A GASTROINTESTINAL COMPLICATION
UNDERDIAGNOSED IN DIABETIC NEUROPATHY
Gonzalo Carpio-Deheza 1 Almendras Mary Cruz 2
tic gastroparesis: a gastrointestinal complication
SUMMARY underdiagnosed in diabe-
Diabetic Gastroparesis is a syndrome characterized by tic neuropathy. Rev Med-Scientific "Life Light". 2011; 2
delay in gastric emptying in the absence of me- (1): 46-50.
cyan of the stomach. The most important symptoms are : 46-50
fullness
postprandial (early satiety), nausea, vomiting and Rev Med-Scientific "Life Light". 2011; 2 (1)
bloating ab- 47
dominal, although in many patients the same is
maintained To diabetes mellitus (DM) is the most frequent cause
asymptomatic. It has been linked to diabetes as neuropathic compromise, affecting up to a
its first cause. 50% of patients with this disease. This is
Although this complication of Diabetes Mellitus is not particularly relevant if one considers the expected
considered increase in
morbidity and / or in the prevalence of DM, more so even if the
mortality, it is important from the point of view of the glucose intolerance can be considered as a fac-
alterations generated subsequently, within them, is the risk of neuropathy. 1-3
alter- Under the term diabetic neuropathy (ND) a
absorption of medicinal products by mouth group of high prevalence syndromes in patients with
mechanisms. diabetic patients. To define ND you can refer concepts
Keywords: Misdiagnosis Diabetic Gastroparesis clinical, biochemical and pathological. 4
Dysautonomy. Likewise, although the most common syndrome is poly-
Keywords: Diabetic gastroparesis underdiagnosed, distal symmetrical neuropathy, 5 which is a sensorimotor
Dysautonomia. neuropathy
"glove and sock" distribu-
1 MD, MSc - Surgeon. Diploma in Tutoring for Research sensory manifestations such as numbness and di-
in but also with painful manifestations), not
Health. Diploma in Family and Community Health. must forget the Dysautonomies, the main ones being
Master in Science clinical manifestations of dysautonomia related to
of University Higher Education. Cochabamba, Bolivia. diabetes mellitus: cardiac, gastrointestinal and
2 Medical Student, Faculty of Medicine-University gastrointestinal
Mayor of which may appear shortly after
San Simón. Cochabamba, Bolivia. after diagnosis. 4
Correspondence / correspondence: Gonzalo Carpio- In 1958, Kassander created the term gastroparesis day-
Deheza beticorum, to describe the process of atony and loss
e-mail: gcd_smed@hotmail.com of the gastric emptying observed in some patients
Received for publication / Received for publication: diabetics. 6 In recent years, with the inclusion of ac-
19/07/2011 paradigm of medicine, as it is "the Integral-
Accepted for publication / Accepted for publication: "the need to touch non-to-
26/07/2011 in many medical schools.
This article should be cited as Carpio-Deheza G, 46
who is the General Practitioner and no longer the
almonds MC. Gas- Specialist, that
diabetic troparesis: an underdiagnosed gastrointestinal which will handle the greatest number and diversity of
complication and if you are not aware of complications
in diabetic neuropathy. Rev Med-Scientific "Life Light". arise in pathologies so common in our environment
2011; 2 (1): 46-50. Diabetes as it is (with a prevalence of 7.2%), 7
This article Should be cited as: Carpio-Deheza G, will remain therapeutic for VO, both for DM and
almonds MC. Diabetic-

Rev Méd-Cient “Luz Vida”. 2011;2(1) :46-50

for other pathologies, which a posteriori, will not give
you a good
I predict their patients.
DEVELOPMENT
Although Gastroparesis literally means paralysis
of the stomach, Diabetic Gastroparesis (GPD) has been
defined in different ways, being the most accepted:
S índrome characterized by delayed emptying gas-
in the absence of mechanical obstruction of the
go. 8 major symptoms are full post
prandial (early satiety), nausea, vomiting and bloating
abdominal, 9 even though in many patients the same
remains asymptomatic. 10
This is not a pathology that is considered high morbi-
the majority of studies consider it to be
low prevalence, but when specifically questioned
Gastrointestinal symptoms increase. eleven
Gastroparesis is an identified complication of
diabetes mellitus and is classically considered to occur
in people with long-standing type 1 diabetes mellitus
and other associated complications, such as retinopathy,
ne-
fropathy and peripheral neuropathy, suggesting a
frequency of presentation of 25 to 55% of the patients
with type 1 diabetes mellitus was 12.13, also described,
this complication in approximately 30% of patients
tes with type 2 diabetes mellitus 14
However, both in type 1 diabetes mellitus and
in type 2 diabetes mellitus have been published indexes
very variable gastric emptying. Thus 15
it can be concluded that diabetic gastroparesis,
between 10-76% of individuals with diabetes melli-
with eight to ten years of evolution of the disease. eleven
Also an interesting fact is that gastroparesis is seen
in type 1 and 2 diabetes, as in patients with and
without associated complications of diabetes. 16.17
Pathophysiology
The causes of diabetic gastroparesis should be
siderarse as multifactorial, 18 as in the rest
of the ND, so based on the hypotheses raised
by several authors the following scheme could be
elaborated,
which is based on two important alterations 1. The
Nervous Alteration and 2. Vascular Alteration, both
alterations caused by different factors
presence of hyperglycemia and a decrease in
Insulin and / or its action.
Alterations in gastric motility derived from
mentioned above are mainly: deterioration in
the relaxation of the gastric fund altering in this way
content accommodation, changes in motility
given by tachy or bradytriasis and antral hypomotility
after duodenal contraction, secondary to the
of phase 3 of the migratory motor complex. The
pylorus-spasm is observed which also contributes
to deteriorate gastric emptying. 19
Presentation Clinic
Rev Méd-Cient “Luz Vida”. 2011;2(1) :46-50
A few years after the beginning of clinical diabetes,
many
patients develop signs of autonomic neuronal damage.
ranging from asymptomatic changes in the velocity of
conduction of the nerve, autonomic dysfunction
with risk of life. 16
Autonomic neuropathy leading to a loss
of vagal tone and increases in sympathetic activity may
to produce gastric dysrhythmias that predispose to the
gastroparesis. 16.17
The manifestations of diabetic gastroparesis are
unspecific; approximately 50% of patients
are asymptomatic or coincide with other pathological
processes.
gastrointestinal gestations, peptic esophagitis, biliary
reflux,
candidal esophagitis and bezoars, which make it difficult
to
diagnosis. 10
Symptoms include nausea, vomiting,
prana, fullness and abdominal discomfort. Apparently,
pre-
abdominal abscess and fullness is associated with
particular with the magnitude of the emptying delay.
15,20
However, the severity of the symptom is not necessarily
is correlated with the degree of gastric stasis. 14
Some patients with severe symptoms may have
almost normal or normal drainage patterns, since
in these patients, it is possible that dyspeptic symptoms
are due to other abnormalities, which include
deterioration of
background relaxation, gastric slow wave dysrhythmias
or visceral hypersensitivity. 14,15
Changes in gastric emptying may affect
the postprandial concentrations of glucose in
blood, whereas gastric emptying delay
contributes to poor glycemic control
to the unpredictable supply of food to the duodenum.
15,21,22 The
deterioration of gastric emptying with administration
of exogenous insulin may produce hypoglycaemia
mia and other complications in these patients.
have a basic pathology such as Diabetes.
Diagnostic
Although the literature mentions a frequency of presence
quite different, ranging from 10-76%, in terms of
GPD refers, it is increasing, through the
performing a good history and physical examination
full.
Within the diagnostic supports we can make
to have a definitive diagnosis are:
Table 1. Tests to assess the myoelectric motor functions
and
gastric 47
Proof Advantage Disadvantage
Radiological Ideal standard Exposure to bioelectric gastric traction practice and
study radiation (mo- activity carry it out;
evils
upper given) gastric (EGG) Invasive
gastrointestinal

with barium
Testing to Measures the Research
Scintillation Noninvasive Exposure to assess response of Technique
radiation (me-
gastric proximal The motion
nima) accommodation gastric artifact
modulation
Breath tests It allows to Requires can make
evaluate absorption in interpreting
using 13 C difficult.
of solids and not thin, he-
liquids of records;
and pulmonary Invasive
excretion

normal
Gastric Measures the Research
Ultrasonograph Noninvasive Requires Barostat combination of technique;
y experience for
accommodatio The balloon
for changes in images and n and may interfere
the interpretation sensitivity with
antral area the
Resonance Noninvasive It mainly accommodatio
Imaging measures the n
empty-
magnetic Proof of satiety Simple Not well-
of liquids; standardized
or
Dude, it takes
time every
Testing to Physiological It requires
assess specialized

activity and
Source: Adapted from Parkman HP, Hasler WL, Fisher
gastric computer RS. Review
contractile technique on the diagnosis and treatment of
gastroparesis. Rev Gas-
troenterol Mex. 2005; 70 (3): 325-360.
Driving
Manometry Values the Invasive
The main goals of the treatment are to maintain
contractility in adequate nutritional status, optimize the effect of
antroduodenal
periods of hypoglycemic therapy, mainly of insulin and
improve the associated symptoms. This will
fasting and
have adequate pre and postprandial glycemia values,
postprandial maintenance of normal body mass indexes and
thus reducing the commitment of target organs. 18
Key principles in the management of gastroparesis
are the correction of aggravating factors, in-
Testing to Measures Experience is including optimization of glucose and electrolytes
assess relaxation and required for levels, provision of nutritional support; and the use of
prokinetic and symptomatic treatments. 2. 3

Rev Méd-Cient “Luz Vida”. 2011;2(1) :46-50

The management can be adapted to the severity of the 50 mg with or without
condi- according without Tegaserod
tion, which is classified according to the capacity of man- to Eri- 2-6 mg
have adequate nutrition and responsiveness necessary. thromicin, IDB every
to therapy. 23.24 40- day, or
Thus, mild gastroparesis was characterized by 250 mg Erythromy
for symptoms that are easy to control: TID before cin 40a
weight and maintenance of nutrition in a re- meals, 250 mg
or making small changes in diet. The and TID all
gastroparesis is associated with symptoms of gra- Dimenhyd the days
moderate degree, partially controlled by the rinate 50 before the
nutrients is maintained through the use of adjustments mg if meals, and
in diet and lifestyle, and hospital treatment did not necessary, Dimenhyd
It's very common. n gastroparesis with gas insufficiency or rinate,
n gastroparesis with gas- Prochlorpe 50 mg
symptoms are refractory in spite of the razine according
: 46-50 25 mg to
according necessary,
Page 4 to Proclorpe-
Rev Med-Scientific "Life Light". 2011; 2 (1) necessary. razina, 25
49 mg
medical care, nutrition can not be maintained through as required
and visits to emergency rooms or hospitalizations are intrave-
compulsory 2. 3 5-HT3
antagonist
Table 2 summarizes recommendations for the (for
jo based on consensus recommendations data 15.24 example,
available, and clinical experience. Ondsetron
Table 2. Diabetic Gastroparesis Management )
Severity of disease Treatment It is not It is not Gastrosto
(% typical gastric retention in 4 hours) Do not necessary. necessary. my,
Pharmace catheter
Treatment Mild Moderate Severe
utical of
(10-15%) (16-35%) (> 35%)
decompres
48
sion and
Consume In the In the Routinely,
PEY tube
of presence presence and
for
food of of the use of
food,
homogene symptom. symptom. supplemen
nutri-
ous ts
parenteral
zada nutritional
administra
supplemen
tion, or
ts.
use of
stimulatio
Suppleme Rarely Caloric PEY can
n
nts needs to. fluids per be
gastric.
Nutrition oral or, in necessary.
rare cases
occasions,
for the
PEY: Percutaneous endoscopic jejunostomy. Source:
PEY tube
M. Camilleri
Treatment Metoclopr Metoclopr Metoclopr
Diabetic Gastroparesis. N Engl J Med. 2007; 356: 820-9.
Pharmaco amide amide 10 amide 10
Surgical Treatment
logical 10 mg mg TID mg TID
Surgery is rarely indicated for the treatment of
according before before the
gastroparesis, except to rule out other disorders
to the meals food for
or to install decompression or feed pipes
require for you you
tion. A systematic study concluded that the data are
and Domperid Domperid
insufficient to provide support for gastric
Dimenhyd one 10-20 one 10-20
in the treatment of patients with diabetic gastroparesis
rinate mg TID mg TID
tica. 25.26
before the before the
Complications of Diabetic Gastroparesis
foods, meals with
The consequences of diabetic gastroparesis are

Rev Méd-Cient “Luz Vida”. 2011;2(1) :46-50

multiple disorders including hydroelectrolytic disorders,
nutritional deficiencies, weight loss, poor control
glycemia which in turn alters gastric motility, the
bezoares that are a rare complication generated by the
retention of undigested food
time of contact for some drugs and a
increase in the risk of bronchoaspiration in the
which require anesthesia for these patients. 19
patient with GPD has a greater tendency to develop
gastric dilation during acute episodes of gastric
ketoacidosis, 22,24 which may require aspiration probe
during long periods.
Esophageal candidiasis affects approximately
15% of patients, possibly due to stasis and
gastroesophageal secondary to reflux GPD. 27.28
DISCUSSION AND CONCLUSIONS
Diabetic gastroparesis has been for a long time
underdiagnosed and neglected, before the rest of neuro-
diabetic patches presented by a patient, in the different
population groups, and has only been diagnosed as
pathology was already well advanced.
Now, while this complication of Diabetes Melli-
is not considered as one that increases
morbidity and mortality, it is important to
from the point of view that patients generally
Diabetics not only have diabetes, but also present
diabetes and other chronic pathologies added, which
also need a therapy based on medical-
that if the doctor (usually
general and / or recently graduated), does not know about
this complication will continue to maintain treatment for
of other pathologies, even worse will
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