The stomach failure of diabetes, known as the “diabetic stomach,” often develops slowly, but over time, the symptoms can become unwilling to ignore once they begin to affect every part of your life.
It is estimated that up to 50% of diabetics can experience some degree of gastroparesis in their lifetime. However, symptoms can vary widely from person to person, and the condition is often misdiagnosed.
What is stomach failure in diabetes?
Gastroparesis is a known complication of both type 1 and type 2 diabetes, affecting the body’s ability to properly digest food.
The National Institute of Diabetes and Kidney Diseases and Kidney Diseases (NIDDK) defines stomach deficiency, also known as delayed gastric emptying, as an obstacle that slows or stops food movement from the stomach to the small intestine, even in the absence of obstruction.
Diabetes-related gastroparesis usually occurs when hyperglycemia levels, including the vagus nerve, which is important for digestive function, damage the entire body.
As a report of Diabetes Spectrumthe American Diabetes Association (ADA) journal states that elevated blood sugar levels can lead to chemical changes in the nerves, causing damage to blood vessels that cause oxygen and nutrients to be delivered.
Damage to the stomach muscles can lead to poor functioning or, in more serious cases, completely incapacitated. This makes it difficult for the stomach to move food through the digestive tract.
If food stays in the stomach for a long time, it can cause bacterial overgrowth as food fermentation.
The ADA also points out that food can become hardened into solid masses called bezoles, leading to nausea, vomiting and potentially dangerous disturbances in the stomach.
The larger bzoar can prevent food from entering the small intestine, and can be life-threatening if left untreated.
Gastric failure in diabetic patients despite healthy blood sugar levels
Gastric failure is usually associated with hyperglycemia levels, but even if A1C (a measure of glucose management over the past 2-3 months) and blood glucose levels are within healthy ranges, it can still occur in people with diabetes.
In such cases, diabetes complications often occur not alone but alongside other conditions.
For example, someone may experience both gastric failure and retinopathy (retardation of the eye), or a combination of peripheral neuropathy and retinopathy.
Signs and symptoms of gastroparesis in diabetes
Symptoms of gastroparesis go beyond typical digestive problems. Like many diabetic complications, gastroparesis slowly develops, so early signs may not be noticed until they become severe enough to disrupt daily life.
Common symptoms reported by ADA and NIDDK include:
- Nausea after eating
- Vomiting after eating
- It feels full after eating only a small amount
- Mild to severe bloating after meals
- Upper stomach pain (upper abdominal pain)
- Gradual and unexplained dose reduction
- Loss of appetite
- Unstable blood glucose levels after meals despite accurate insulin administration
- Heartburn or acid reflux
- Frequent belch
- Oral drug absorption disorders
- Convulsions and convulsions in the stomach wall
“It’s really important to discuss clear stomach and digestion issues with your healthcare team,” says Susan Weiner, MS, RDN, CDCES, CDN, FADCES, and the 2015 Aade Diabetes Educator of the Year. “This can include chronic constipation, bloating, and recent, unexplained spikes of blood sugar.”
Weiner emphasizes the need for healthcare professionals to create an open and supportive environment for patients, as it can be uncomfortable to discuss digestive issues.
Having a supportive health care team is important for effective treatment, as blood glucose control, especially gastroparesis, brings a unique layer of frustration.
What aggravates gastroparesis
Several factors can worsen gastroparesis, including:
- High-fiber foods
- High-fat foods
- Large meals
- Stress, anxiety, or depression
- Smoking a cigarette
- alcohol
- Carbonated drinks (soda, seltzer, etc.)
Medications that can worsen gastroparesis
It is important to review your doctor about the medications you are taking for other conditions. This is because some people can indirectly affect the digestive system and can worsen the symptoms of gastroparesis.
Be sure to notify the medical professional who prescribes new medication that you have gastroparesis. Even medications used for asthma, such as inhalers, can affect the digestive system.
The following medications that can worsen gastroparesis:
- Narcotics (e.g. codeine, hydrocodone, morphine, oxycodone, tapentadol)
- Certain antidepressants
- Some anticholinergic drugs (drugs that block nerve signals)
- Medications used to treat overactive bladder
- Muscle relaxants
- Symlin (common name Pramlintide), diabetes medication
Complications of gastroparesis in diabetes
If your body is unable to properly digest food, various complications can occur. Sometimes even before the official diagnosis of gastroparesis is made. These complications include:
- Frequently dehydration due to vomiting
- Malnutrition caused by malabsorption of nutrients
- It’s difficult to manage your blood sugar levels after meals
- You’ll have trouble getting low calorie intake or getting enough calories
- bezoars (solid masses of undigested food in the stomach, as highlighted above)
- Difficulty in maintaining healthy weight due to reduced food intake
- Malnutrition, pain, and other symptoms reduce quality of life
Laura’s Story: My First Symptoms
“My first symptoms began six years before my diagnosis,” Laura Marie said she is resistant to diabetes. Laura has been living with type 1 diabetes since 2002 when she was 16 years old. She was officially diagnosed with diabetes gastroparesis in 2014.
“My symptoms of gastroparesis included nausea and vomiting. I often feel nausea in the morning and vomit for days after indigested food.”
As her condition progressed, Laura began to experience intense bloating until her clothes became uncomfortable by the end of each day. Furthermore, she was suffering from severe stomach cramps and pain.
“My blood sugar level was also very unstable. My blood sugar level went low right after I ate, and then it was only a few hours after high blood sugar, especially at night.”
By using a continuous glucose monitor (CGM), Laura was able to track these unstable blood glucose patterns, giving valuable insight into how her condition affected her overnight levels.
However, the most frightening aspect of her symptoms was her frequent visits to the emergency room for diabetic ketosidosis (DKA). Laura was hospitalized about every six months due to uncontrollable blood sugar that led to DKA.
“When I finally got burned out, irritated and scared, it felt like I was at DKA for the 100th time. I told the healthcare team I was desperate for testing and diagnosis.”
Laura had previously asked her to get tested for gastroparesis for diabetes, but her doctors dismissed her concerns and said she was “too young” for complications.
Ultimately, her history of autonomic nervous system disorders (damage to the nerves controlling the body system) made her a powerful candidate for gastroparesis testing.
Diagnosis of gastroparesis in diabetes
There are several ways to test and diagnose diabetic gastroparesis.
Before performing complex procedures, doctors usually start with a simple assessment of overall health. This can indicate the need for further testing. These initial assessments include:
- Feel the stomach due to softness, stiffness, or pain
- Using a stethoscope to hear unusual sounds in your stomach
- Check your blood pressure, temperature and heart rate
- Looking for signs of malnutrition and dehydration (may involve blood tests)
Once these basic assessments have been completed, the next step is to determine how quickly the stomach digests food and emptys it into the intestines. NIDDK lists the following tests as current methods for diagnosing gastroparesis:
Barium X-ray
You will be asked to fast for 12 hours and then drink a thick liquid containing barium. Barium covers the stomach and makes it visible by x-rays.
A healthy stomach should be completely empty after 12 hours. If you still see food debris, it clearly indicates that your stomach is not properly empty.
However, X-ray hunger does not necessarily rule out gastroparesis. If symptoms persist, you may be asked to repeat the test as delayed vents may differ each day.
You may also be asked to eat barium meal, known as “barium beef steak.” This is more effective in diagnosing gastroparesis than liquid tests, as it is more difficult to digest solids.
Radioisotope gastrostitis scan (scintigraphy)
In this test, you eat a meal containing radioactive substances called radioisotopes. After that, you are lying under a machine that tracks how quickly food moves through the digestive system.
If more than half of the food is still in the stomach after 2 hours, this indicates gastroparesis.
Breathing test for stomach content
This test will eventually return to your intestines and consume a diet containing substances that return to your breath.
After 4 hours, breath samples are taken to assess how much of the material is still present and to reveal the rate at which the stomach is empty.
Gastric compression test
In this test, a thin tube is passed through the throat to the stomach while eating a normal meal and sedating.
The tube measures stomach muscle activity to determine food digestion. Delayed digestion is indicated by abnormal activity in the test.
“SmartPill” or wireless motility capsule
This innovative test involves swallowing small electronic capsules that pass through the entire gastrointestinal tract. The capsule sends data to devices in your pocket and tracks how quickly food travels through the digestive system.
Ultimately, the capsule will pass naturally during defecation.
Other diagnostic tests that exclude other conditions
To prevent your symptoms from being caused by another condition, your doctor may also recommend the following tests:
Upper endoscopy
During sedation, a thin tube (endoscope) passes through the throat and into the stomach to check for other potential problems.
Ultrasound
This non-invasive test uses sound waves to create images of the stomach and nearby organs, excluding conditions such as gallbladder disease and pancreatitis.
Treatment of gastroparesis in diabetes
One of the most difficult aspects of managing gastroparesis is adjusting how and how you eat. NIDDK proposes the following dietary guidelines to reduce symptoms and improve comfort.
- Eating a low fiber diet
- Eating a low-fat diet
- Instead of a large meal of 2-3, eat smaller, more frequent meals (5-6 a day)
- Chew food thoroughly and slowly
- Choose softer, well-cooked foods rather than hard or raw food
- Choose non-carbonated drinks
- Limit or avoid alcohol
- Drink plenty of water and healthy liquids like low-fat soup
- Choose plant juices with low fiber and no added sugar
- Drink low-sugar sports drinks with electrolytes
- Take a short walk after meals
- Do not lie within 2 hours of eating
- Take multivitamins every day during your meal
Following these recommendations can help you manage your symptoms, but can also be frustrating.
A low fiber diet is very important, for example, as fiber can be difficult for the stomach to process. However, this makes it difficult to get enough fruits and vegetables.
Similarly, small, frequent diets can be easier to digest, but may require more planning and preparation.
Weiner says that all people experience gastroparesis differently, so some of these guidelines may work for you, but others may not need it. Finding the right nutrition approach requires time and adjustment.
Eating slowly and chewing thoroughly is a universal recommendation that benefits almost everyone. Cooking vegetables rather than eating them raw can also help relieve digestion. For example, carrots are much easier on the stomach when cooked, rather than eating them raw.
However, drinking liquids can sometimes fill your stomach if it’s too fast. This can be a problem if you have constipation or limited stomach volume.
To balance hydration and nutrition, weiners recommend drinking liquids between meals rather than during meals.
Smoothies are a useful solution as they break down fruits and vegetables into small, manageable pieces and are easy to digest. However, it is important to choose the low sugar option, as fruit blending can concentrate sugar.
Medications to treat diabetic gastroparesis
Unfortunately, there is no single drug that can be useful for all people with diabetic gastroparesis. Treatment often involves a lot of trial and error, and even if the medication is effective, it may provide relief for a short period of time.
One of the medicines that some people find useful is domperidone. This is available in a prescription in countries like Canada, but it has not been approved by the US Food and Drug Administration (FDA).
People in the US may have access to this drug with certain online pharmacies or with special approval.
Some reported significant improvements, while others, like Laura, found that its effectiveness declined after a few days due to side effects.
Due to variability in responses, it is important to work closely with your healthcare provider to find the right treatment.
For a more extensive list of medications used to treat gastroparesis, see this study in the Journal Clinical treatment.
Experimental treatment under investigation
Researchers are continuously investigating new medications and procedures to improve treatment for gastroparesis.
A promising drug therapy currently under development is called reramorelin. In a phase 2 clinical study, the drug demonstrated its ability to speed up stomach content and reduce vomiting episodes.
Although reramorelin has not yet been approved by the FDA, further research is currently underway to assess its effectiveness.
In addition to medication, researchers are investigating new treatments that include slim tubes, known as endoscopes inserted into the esophagus.
A procedure known as endoscopic craniotomy or gastroscopic myotomy (G-POEM) has also been studied.
This procedure cuts pyrrolus, the muscle valve between the stomach and the small intestine, creating a more distinct pathway for food passage.
Initial results are promising for people with gastroparesis, but additional research is needed to confirm its long-term effectiveness.
Laura’s Story: Managing my nutrition regarding Gastroparesis
“My diet is still my biggest struggle,” Laura said. “Sometimes, I can eat anything without digestive issues. But the same food makes me feel lethargic, nauseous, painful, and even depressed.”
Laura explains that despite efforts to identify patterns of what causes her symptoms, nothing consistent has emerged.
“One day, fruits and vegetables don’t cause any problems. The next day, they’re a complete disaster. My relationship with food has changed dramatically since I was diagnosed with gastroparesis.”
Due to these challenges, Laura avoids eating out at restaurants and attending many social gatherings. “If you feel sick, avoid eating all day long for the day, fearing that eating something could cause a flare-up.”
During severe or acute flare-ups, Laura rarely eats for weeks until symptoms subside. “When my appetite disappears, I get nauseous when I try to eat. I quickly lose weight and become dehydrated.”
The unpredictability of how her stomach will respond to all kinds of foods — not to mention the general triggers — is undoubtedly the most frustrating part of living with gastroparesis.
Surgical treatment for severe diabetic gastroparesis
According to NIDDK, severe cases of gastroparesis may require alternative food delivery methods to ensure that they receive the right calories and nutrients. While these options may seem overwhelming, some are less invasive than others.
Feeding tube
In this procedure, during sedation, the doctor places the tube in the mouth or nose and extends into the small intestine.
You are eating a liquid diet, and the feeding tube completely bypasses the stomach and allows nutrients to enter directly into the small intestine. There are two types of feeding tubes to discuss with your healthcare team.
- Traditional oral or nasal feeding tube (short term)
- Intestinal tissue building tube (long term)
Intravenous nutrition (parenteral nutrition)
Parenteral nutrition is another way to provide nutrients without the use of the stomach. This includes short-term intravenous solutions that deliver liquid calories and nutrients directly into the bloodstream.
Gastric somy airflow
This procedure is designed to relieve stomach pressure. Small openings are created in the sides of the abdomen and in the stomach.
The tube is located in this opening, which drains the contents of the stomach into the external device. This helps relieve severe stomach pain and pressure.
Electrical gastric stimulation (GES)
GES is a surgical option, particularly for diabetes-related gastroparesis. A small battery-powered device is implanted under the skin of the lower abdomen. It sends small electrical pulses to the nerves and muscles of your stomach, enhancing movement and digestion.
This method can be used as a long-term treatment for severe nausea and vomiting in people who are not responding to other medications or treatments.
Management of diabetes in a different way than gastroparesis
One of the biggest challenges in managing blood glucose levels using gastroparesis is the unpredictability of digestion. You have no idea when the food you eat will be completely digested, absorbed into the bloodstream and affect your blood sugar levels.
On some days, diets may be digested normally, while on other days, digestion can be unpredictably slower, and accurate insulin dosages are almost impossible.
CGM is one of the most useful tools for managing this. Diagnosis of gastroparesis in diabetes should qualify for CGM health insurance coverage. So make sure your doctor highlights this diagnosis in your documents.
Laura’s Story: Control of blood glucose due to gastroparesis
Laura’s experience with gastroparesis resulted in severe blood glucose fluctuations.
“I often have hypoglycemia after eating because insulin kicks before the food is digested,” she explains. “Then, a few hours later, my blood sugar levels spike, and it can take some time to get off, especially overnight.”
To manage this, the roller uses a multi-wave bolus function on the insulin pump to allow insulin to be taken up in advance and deliver the rest over several hours.
“It’s a complete guess to figure out how long my food will take to digest, so I use Freestyle Romi to track my blood sugar levels,” she says.
Freestyle Libre is not a traditional CGM like Dexcom or Medtronic, but it provides instant data every time you scan the sensor and helps you catch blood sugar spikes.
“If you notice that it’s rising sharply, take more insulin and monitor everything closely.”
However, it is difficult to prevent rapid spikes and manage corrective doses. For people with type 1 diabetes, it can be difficult to balance carbohydrates, insulin, and blood sugar, but for people with gastroparesis, the unpredictable height makes them tired.
“It’s a very difficult balancing act, and I don’t think I can manage it without CGM or freestyle ribble.”
Laura’s advice for other people with gastroparesis
In addition to talking to a doctor, Laura strongly recommends independently investigating this condition.
“We’ve noticed that many medical professionals don’t fully understand this condition, but I’m grateful for their honesty about it. Together, we worked to manage it as much as possible.”
She also encourages people to join support groups or online forums to connect with others living with gastroparesis.
“Patients are really experts. They have countless tips and tricks to make life a little more manageable in this difficult situation.”
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