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.