Gastrointestinal Complications of Diabetes
Yasser Shaib MD, MPH, FASGE
Associate Professor of Medicine, American University of Beirut Medical Center
Clinical Associate Professor of Medicine, Baylor College of Medicine (Houston)
Diabetes is a systemic disease that affects many organ systems including the digestive system. In the digestive system, elevated blood sugar levels could lead to several problems and around 75% of diabetic patients will report significant gastrointestinal symptoms at some point. These problems (collectively known as gastrointestinal complications of diabetes) include mainly acid reflux, gastroparesis and enteropathy.
Acid Reflux: Occurs when the acidic contents of the stomach flow back into the esophagus leading to heartburn and chest discomfort.
More than one third of diabetic patients report having gastroesophageal reflux symptoms. Of note, peripheral neuropathy has been identified as an independent risk factor for esophagitis (significant inflammation of the esophagus secondary to acid exposure) in type 2 diabetic patients. Erosive esophagitis affects two thirds of patients with neuropathy and one third of those without neuropathy.
Gastroparesis: Also called delayed gastric emptying, is a disorder that slows or stops the movement of food from the stomach to the small intestine.
Approximately 5 to 12 percent of patients with diabetes report having symptoms consistent with gastroparesis. It is more common in women and can present as early satiety, nausea, vomiting, bloating, postprandial fullness, or upper abdominal pain. Gastric emptying is best evaluated by a special scan which measures the transit of food through the stomach using a radiolabeled meal.
Enteropathy: Refers to small and large intestinal dysfunctions that occur in diabetic patients causing diarrhea, constipation or fecal incontinence.
Diabetic enteropathy is common in patients with longstanding diabetes. Reduced bowel motility results in constipation that may lead to overflow incontinence which is the involuntary release of stools from an overfull bowel. On the other hand, neuropathy, malabsorption and bacterial overgrowth (expansion of bacteria in the small intestine) cause diarrhea which becomes especially bothersome when associated with fecal incontinence due to neuropathy affecting the internal and external anal sphincters.
Management: Similar to other complications of diabetes, tight glycemic control is the first step in preventing gastrointestinal complications. Weight loss and a high fiber diet help prevent reflux and promote regular bowel movements.
More targeted medical therapy can be used for specific problems. For example, proton pump inhibitors and prokinetic agents help control acid reflux symptoms. Prokinetic agents are also helpful for gastroparesis. Diarrhea and constipation are best managed with stools softeners and antidiarrheal agents as needed and antibiotics are used if bacterial overgrowth is suspected. Refractory symptoms may require more invasive interventions such as gastric pacemaker for gastroparesis.
It is important for patients and physicians to recognize and treat these problems as they greatly impair well-being and quality of life of patients. In difficult to manage patients we recommend a multidisciplinary approach involving a diabetes specialist, dietitian and a gastroenterologist.
Gastrointestinal Complications of Diabetes
Cecilio R. Azar, MD
Clinical Associate, GI Division AUBMC
Head of GI Division, MEIH
Diabetes mellitus can affect anywhere is the gastrointestinal (GI) tract from the esophagus to the anorectal area.
The most common GI complications of diabetes include gastroparesis (lazy stomach or delayed gastric emptying), intestinal enteropathy (which can cause diarrhea, constipation, and fecal incontinence), and nonalcoholic fatty liver disease. These complications and their symptoms are often caused by abnormal gastrointestinal motility, which is a consequence of diabetic autonomic neuropathy. Such complications are associated with poor blood glucose control and not necessarily the duration of diabetes. Esophageal manifestations include abnormal movements, spontaneous contractions, and impaired lower esophageal sphincter tone, result in heartburn and difficulty swallowing (dysphagia). Gastroparesis or delayed gastric emptying is a common consequence of diabetes. Patients with gastroparesis may present with early satiety, nausea, vomiting, bloating, postprandial fullness, or upper abdominal pain. Delayed gastric emptying contributes to poor blood glucose control and may be the first indication that a patient is developing gastroparesis. Intestinal enteropathy in patients with diabetes may present as constipation, diarrhea, or fecal incontinence. Constipation is one of the most common complications of diabetes. Almost half of patients with diabetes reported constipation or increased use of laxatives. Patients may also develop diarrhea, which leads to malnutrition, and weight loss. Sometimes anti-diabetic medications (such as metformin) can cause diarrhea. Nonalcoholic fatty liver disease is the term used to describe a liver condition in patients who have a pathology resembling alcohol-induced liver injury but lack a history of significant alcohol consumption. It is often associated with diabetes and obesity. In some cases, nonalcoholic fatty liver disease may progress with varying degrees of inflammation, in rare cases to cirrhosis.
So in summary, most gastrointestinal complications can be avoided and controlled by strict normalization of blood glucose levels.
Diabetes and Nonalcoholic Fatty Liver Disease
Tarek Abou Hamdan, MD
Gastroenterologist & Interventional Endoscopist
Clemenceau Medical Center
Nonalcoholic steatohepatitis or NASH is a common, often “silent” liver disease. It resembles alcoholic liver disease, but occurs in people who drink little or no alcohol. The etiology is unknown, but the disease is often associated with type 2 diabetes and obesity.
The major feature in NASH is fat in the liver, along with inflammation and damage. In the event of presence of fat in the liver, but no inflammation or damage, this problem is called non-alcoholic fatty liver disease (NAFLD). Both NASH and NAFLD are becoming more common, possibly because of the greater number of people with obesity. In the past 10 years, the rate of obesity has doubled in adults and tripled in children. Obesity also contributes to diabetes and high blood cholesterol, which can further complicate the health of someone with NASH.
NASH is generally suspected in patients with persistent elevation in hepatic transaminase levels. When further evaluation shows no apparent reason for liver disease (such as medications, viral hepatitis, or excessive use of alcohol) and when imaging studies of the liver show fat, NASH is suspected. The only means of proving a diagnosis of NASH and separating it from NAFLD is a liver biopsy.
NASH is usually a silent disease with few or no symptoms. Patients generally feel well in the early stages and only begin to have symptoms —such as fatigue, weight loss, and weakness— once the disease is more advanced or cirrhosis develops. The progression of NASH can take years, even decades. Not every person with NASH develops cirrhosis, but once serious scarring or cirrhosis is present, few treatments can halt the progression. Patients with diabetes, an elevated body mass index, and fibrosis are at higher risk for progression.
Currently, no specific therapies for NASH exist. General recommendations include a balanced and healthy diet, increase physical activity, and avoid alcohol or unnecessary medications. Gradual weight loss (5-10% over 6 months-1 year) and good control of blood glucose levels (HbA1C < 7%) are recommended. NAFLD patients with dyslipidemia should be treated with statins. Experimental approaches in patients with NASH include addition of antioxidants, such as vitamin E or pentoxifylline. Whether these substances actually help treat the disease is not known. Drugs targeting insulin resistance, such as thiazolidinediones and metformin, are approved for diabetes therapy but not for NAFLD/ NASH, and should be considered experimental. They have shown benefit in lowering hepatic transaminase levels and improving ultrasound findings; however, there is no evidence that long-term use of these agents improves clinical outcomes. Because good evidence is lacking, routine use of these drugs simply to normalize hepatic transaminase levels is not recommended.
Diabetes Metabolic Syndrome & Probiotics
Prof. Georges H. Boutros, Hepato Gastroenterologist
Dr. Salah Ezzedine, MD
DIABETES IS AN INCURABLE CHRONIC DISEASE WHICH, IF NEGLECTED, CAN INDUCE SEVERE VISCERAL COMPLICATIONS, SOMETIMES FATAL.
It reflects an abnormality in insulin, which is the principal, if not the exclusive element for the regulation of blood sugar. Secreted by the pancreas, this hormone has an essential function allowing the penetration of glucose in the cells of the organism, providing them with the necessary energy for their metabolism.
THE METABOLIC SYNDROME
The metabolic syndrome is becoming increasingly common.
It associates abdominal obesity and at least two of the following problems:
- Type 2 diabetes or fasting-plasma glucose >110 mg/dl.
- High level of triglycerides
- Low level of HDL-cholesterol
- Arterial hypertension All of these risk factors promote the development of atherosclerotic cardiovascular disease. In addition, poor cardiorespiratory fitness is an independent and strong predictor of metabolic syndrome in both men and women
Diabetes is a ubiquitous disease on a continuous rise. In 2011, there were 246 million diabetics in the world; one would expect more than 400 million in 2025. In Lebanon, the WHO estimates the risk of diabetes about 13% and states that it may well reach 26% in 2020.
Nowadays, obesity is the second most important health problem. There were 400 million obese people in 2011, and more than 700 million are expected by 2023.
Increased body weight is a major risk factor for metabolic syndrome. This syndrome was present in 5 percent of those at normal weight, 22 percent of those who were overweight, and 60 percent of those who were obese.
The metabolic syndrome has several causes:
- Sedentary lifestyle
- Consumption of foods rich in fat and carbohydrates
- Tobacco and alcohol consumption
PROBIOTICS AND MICROBIOTICS
Probiotics are micro-organisms that have beneficial properties for the host, which have the potential to favorably influence the immune system. The intestinal tract is host to a vast ecology of microbes, which are necessary for health.
Our digestive tract is inhabited by a microbial world, called “Microbiote”, excessively rich in bacteria, yeasts, etc. It is dynamic and intelligent. It is our “second brain”. It fulfills several essential functions for the organism, especially in general immunity.
Thanks to new methods of molecular biology and experiments made by instillation of intestinal flora, probiotics now play a major role in the prevention of metabolic syndrome. Several observations and experiments have confirmed this role.
In 2006, an Indian study showed that a yogurt diet enriched with probiotics decreases the risk of diabetes in rats.
Women who take probiotics during pregnancy develop less gestational diabetes. In the same way probiotics decrease abdominal fat and weight in general.
A recent experiment showed a specific improvement of the sensitivity to insulin by prolonged instillation of healthy intestinal flora in the gut of people suffering from metabolic syndrome.
Several probiotic preparations have promised to prevent or treat various conditions. The evolution of our knowledge of probiotics opens the way to develop new therapeutic options for the treatment of diabetes and metabolic syndrome in general.