Diabetic Gastroparesis

Diabetic gastroparesis is delayed gastric emptying from autonomic neuropathy and loss of interstitial cells of Cajal in diabetes.

• Affects 5 to 12% of long standing diabetics, more in type 1.
• Aggravated by hyperglycaemia, which itself slows emptying, and by GLP 1 agonists, pramlintide, opioids.
• Complicates glycaemic control through erratic nutrient delivery.

• Nausea, vomiting of undigested food, early satiety, bloating, upper abdominal pain, weight loss.
• Unexplained glucose lability and post meal hypoglycaemia.
• Other autonomic features and neuropathy.

• Exclude obstruction (endoscopy or imaging).
• Gastric emptying scintigraphy over 4 hours (retention above 10% at 4 hours), with glucose below 275 mg/dL and prokinetics held.
• Review drugs (GLP 1 agonists, opioids, anticholinergics).
• Check electrolytes, HbA1c, TSH.

• Glycaemic optimisation, small frequent low fat low fibre meals, liquid or pureed calories.
• Metoclopramide 5 to 10 mg 30 minutes before meals (maximum 12 weeks), domperidone 10 mg three times daily where available, erythromycin 125 to 250 mg before meals (short term).
• Antiemetics: ondansetron 4 mg, prochlorperazine 5 to 10 mg, mirtazapine 15 mg at night.
• Insulin timing after meals; continuous glucose monitoring; stop GLP 1 agonists if suspected causative.
• Refractory: gastric peroral endoscopic myotomy, gastric electrical stimulation, jejunal feeding, venting gastrostomy.