Type 1 Diabetes And Stomach Pain

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What is gastroparesis?

Gastroparesis¹ is a condition where your stomach and intestines don’t empty food normally. The word “gastroparesis” simply means “stomach paralysis.” Emptying of the stomach is delayed with gastroparesis, but there is no actual blockage.

In people with diabetes, gastroparesis is caused by damage to the intestines or the vagus nerve (which plays a role in controlling muscles necessary for normal digestion) as a result of persistent high blood sugar.

Gastroparesis is a lifelong condition with no known cure, and it can’t be reversed. The condition is marked by recurring flare-ups and periods of remission (where symptoms are mild or non-existent), and treatments aim to reduce the severity and frequency of flare-ups.

Symptoms of gastroparesis

Gastroparesis is a condition of the muscles that are essential for healthy, normal digestion. In a healthy system, the intestinal walls tighten and loosen to squeeze food along the digestive tract. When a person has gastroparesis, the muscles that cause the squeezing are impaired. For that reason, most of the symptoms of gastroparesis are due to poor digestion and overlap with other digestive issues. Possible signs of gastroparesis include:

  • Abdominal pain

  • Frequent vomiting after eating

  • Nausea

  • Bloating

  • Postprandial fullness,² or feelings of food remaining uncomfortably in the stomach

  • Weight loss and nutritional deficiencies

In people with diabetes, a less obvious sign of gastroparesis is the inability to manage blood glucose levels, which is caused by the slow movement of food through the digestive system.

Causes of gastroparesis

There are three subtypes of gastroparesis:

  • Idiopathic gastroparesis: This is the most common type. When we develop a condition and doctors can’t figure out why, they say it’s idiopathic, which simply means “we know you have it, but we don’t know what caused it.” Studies³ show that over one-third of gastroparesis cases are idiopathic.

  • Diabetic gastroparesis: This is the second most common form of gastroparesis and accounts for approximately 29% of all cases.  Notably, there’s evidence⁴ that diabetic gastroparesis may account for around two-thirds of all cases of gastroparesis in African Americans, making it the most common cause, but the reasons are unclear and more research is needed.

  • Postsurgical gastroparesis:⁵ This type of gastroparesis occurs when the vagus nerve (which plays a crucial role in regulating digestion) is damaged during abdominal surgery. 

Gastroparesis is not an autoimmune disease, but there are connections between the two.⁶ Cases outside these three subtypes are typically linked to Parkinson’s disease or connective tissue diseases, such as lupus or rheumatoid arthritis.

Glutamic acid decarboxylase (GAD) antibodies, which are associated with a number of autoimmune conditions, including type 1 diabetes, are also linked to gastroparesis. Elevated levels of GAD antibodies can directly slow down digestive functions.

Risk factors for gastroparesis

Biological sex, age, and race are risk factors for gastroparesis. The condition appears to be more prevalent in African Americans, women, and people in their 50s or older. Beyond that, people with the following conditions are more likely to develop gastroparesis:

Diabetes

People with diabetes are more likely to develop gastroparesis than people without. In one study,⁷ researchers found that people with type 1 diabetes, in particular, were more than 30 times more likely to develop gastroparesis than their age- and sex-matched study counterparts. Interestingly, they found that the best predictor of whether or not a person with type 1 diabetes would develop gastroparesis was the presence of heartburn. 

Acid reflux

Acid reflux can lead to gastroesophageal reflux disease (GERD). It’s unclear whether GERD causes gastroparesis, but it’s common for individuals to be affected by both GERD and gastroparesis simultaneously. 

Symptoms shared by these conditions include nausea, vomiting, and heartburn. Gastroparesis causes a delay in gastric emptying, which can result in food being held in the stomach for longer periods, increasing the risk of acid reflux.

Viral infections

Viral infections may trigger gastroparesis, especially if the infection causes nerve or muscle damage in the abdomen, resulting in nausea and vomiting. 

Symptoms of gastroparesis are generally milder when triggered by a viral infection compared to other causes.  

Smooth muscle disorders

Smooth muscle disorders may result from connective tissue diseases, such as lupus⁸ and scleroderma.⁹ Smooth muscle fibers are found in the walls of the intestines, and a malfunctioning of the smooth muscle in the intestinal walls can slow digestion, leading to gastroparesis. 

Parkinson's disease

Parkinson's disease is a brain disorder that causes unintended or uncontrollable muscle movements. Like many other parts of the body, digestion relies on muscle activity. 

More research is needed on gastroparesis in people with Parkinson’s disease, but one team of researchers¹⁰ found that gastroparesis has been reported in around 45% of people with Parkinson’s. They suspect that the number may actually be much higher because many people with gastroparesis have mild symptoms and may not get tested.

Chronic pancreatitis

People with chronic pancreatitis often experience digestive issues, so the rate of gastroparesis in people with pancreatitis may be drastically underestimated as gastro problems may be brushed off as a typical symptom of pancreatitis. Still, studies¹¹ show that the condition is commonly diagnosed in people with chronic pancreatitis. 

Cystic fibrosis

When we think of cystic fibrosis, most of us think about the disorder’s impact on the lungs, but cystic fibrosis also affects other organs, including the intestines.

Patients with cystic fibrosis are often diagnosed with digestive disorders, including gastroparesis. In a review of current literature,¹² researchers found that 38% of study participants who had cystic fibrosis also had gastroparesis. 

Kidney disease

The kidneys are the body’s filtration system. They’re responsible for removing toxins from the blood and converting waste into urine. In kidney disease, the kidneys don’t filter properly, and there’s a buildup of waste in the body, which can lead to complications, such as malnutrition and issues with emptying the stomach. 

Patients with severe kidney disease are at a high risk of developing gastroparesis.

Turner syndrome

Turner syndrome only affects people born with two X chromosomes — those born biologically female. In this condition, part (or all) of one X chromosome is missing. Turner syndrome is rare and affects people differently. Some people¹³ with Turner syndrome develop gastroparesis, but it’s not clear why. 

Diagnosing gastroparesis

If you have type 1 diabetes and you have signs of poor digestion or difficulty managing your blood sugar, your doctor may suggest checking for gastroparesis. While the condition can’t be diagnosed based on symptoms alone (many other gastro issues have the same signs), these symptoms indicate that diagnostic testing may be necessary. Testing may include: 

Physical exams

Your healthcare provider may start by checking your blood pressure, heart rhythm, and body temperature. They may also:

  • Examine your skin to assess hydration

  • Measure your height and weight to calculate your body mass index (BMI), as a low BMI may indicate malnutrition

  • Apply pressure to different parts of the stomach to check for pain or discomfort

Blood or urine tests

Blood and urine tests are handy tools for healthcare providers. They provide a snapshot of your body’s condition and the status of the different systems within your body. Abnormal blood or urine test results can reveal nutritional deficiencies and organ malfunctioning and indicate the presence of infection or inflammation within the body. 

Endoscopy

An endoscopy is when a healthcare provider uses a small tube with a camera and light on the end to see your digestive tract. A special type of endoscopy called an esophagogastroduodenoscopy¹⁴ (eh-sof-ah-go-gas-tro-dew-oh-den-oh-scop-ee), can be used to assess digestive functioning.

With this test, an abnormal result won’t lead to a conclusive diagnosis. For example, your healthcare provider may be able to see that your digestion is slow, but an endoscopy won't tell them why.  

Gastric emptying scintigraphy (gamma scan)

Scintigraphy, or a gamma scan, is a type of imaging test commonly used to assess digestive function, and it’s the most important test for confirming a gastroparesis diagnosis. 

In gastric emptying scintigraphy, a patient eats a small meal that contains a radioactive substance called a tracer. Soon after, a specially-trained technician uses a camera to capture images of the tracer at different points, keeping track of how long it takes for the tracer to move through the digestive tract.

The consensus is that if more than 10%¹⁵ of the food remains in the digestive tract after four hours, a diagnosis of gastroparesis is likely. 

Treating gastroparesis

Gastroparesis is often treated using a multi-level approach that typically involves changes in eating patterns through dietary guidance and medications to alleviate symptoms.

Prokinetics

Prokinetics are medications that promote proper contractions of the muscles in the intestinal walls. They can help improve how the stomach empties its contents and alleviate acid reflux. 

Metoclopramide

Metoclopramide mutes specific receptors that block movement through the intestine, resulting in improved movement of food through the digestive system. It has been used since the 1970s to improve symptoms of gastroparesis. 

Erythromycin

Erythromycin causes contractions within the digestive tract, improving gastric emptying. It seems to minimize symptoms of gastroparesis, but further investigations are required to evaluate its effectiveness. Because there’s a lack of evidence, treating gastroparesis with erythromycin is an “off-label” use of the drug — that is, the medication’s literature doesn’t mention using it for gastroparesis — so some doctors may hesitate to prescribe it. 

Botulinum toxin

Botulinum toxin relaxes muscles. In severe cases of gastroparesis, injections of botulinum toxin have been shown to improve both gastric emptying and symptoms of the disease. 

The injection is administered into the pyloric sphincter muscle, which regulates the movement of food from the stomach to the intestines. 

Gastric pacing

The implantation of electrodes in the smooth muscle layer of the stomach’s lining is known as gastric pacing. This electrical stimulation activates smooth muscle layers of the stomach by imitating natural wave-like contractions of the stomach. 

Studies have shown that this treatment may reduce symptoms such as vomiting and nausea, but it might not be as effective as other treatments in increasing gastric emptying.

Managing gastroparesis

The key objective of gastroparesis treatment is to improve symptoms as much as possible, maintain stable nutrition, and achieve or maintain a healthy weight. In most cases, gastroparesis can be managed effectively with appropriate diet and lifestyle changes. 

While some medications help gastroparesis, it’s essential to note that others, including some antidepressants and high blood pressure treatments, can make it worse. If you’re taking medications and worry they may trigger gastroparesis flare-ups, speak with your healthcare provider about alternatives.

Foods to avoid

Proper dietary management can help reduce the severity of gastroparesis symptoms. If you have gastroparesis, it’s best to avoid:

  • Foods high in fat

  • Snacking late at night

  • Insoluble fibers, like those found in flour, grains, beans, and potatoes

  • Carbonated drinks, can cause stomach inflammation and swelling

  • Tobacco and alcohol can affect contractions of the stomach and slow gastric emptying

Beneficial foods

Highly nutritious foods that are easy to digest can help minimize symptoms of gastroparesis. They include fruits and vegetables, as well as good-quality sources of protein. Eating lighter meals at regular times will help improve digestion. 

When symptoms are particularly severe, it is recommended to stick with a liquid diet that can include smoothies, soups, and juices. Staying hydrated is essential for people with gastroparesis.

When to visit a doctor

Regardless of whether or not you have type 1 diabetes, you should see your healthcare provider if you have persistent stomach pain with no known cause. Other signs it’s time to see a doctor include vomiting, unexplained weight loss, and dehydration. A doctor will work with you to find the source of your stomach pain or digestive issues, and if you need medical treatment, they’ll prescribe the medication that best suits your needs.

Your primary healthcare provider may also recommend seeing a nutritionist who can help you manage your symptoms through diet and improve your overall health. 

If your symptoms are sudden or severe, don't wait. Instead, call 911 or go to your nearest hospital or emergency clinic. 

The lowdown

Gastroparesis is a disease characterized by muscle impairment in the digestive tract. It’s a common cause of stomach pain in people with type 1 diabetes.

Although there are numerous treatment options for gastroparesis that may provide relief, most people with mild and moderate cases will benefit from dietary and lifestyle adjustments. There is no cure for gastroparesis, but most people with the condition can lead normal lives while managing their symptoms through lifestyle choices and, in some cases, medications.

  1. Clinical guideline: Management of gastroparesis (2013)

  2. Early satiety and postprandial fullness in gastroparesis correlate with gastroparesis severity, gastric emptying, and water load testing (2017)

  3. Idiopathic gastroparesis (2016)

  4. The impact of risk factors on gastroparesis at an urban medical center (2020)

  5. American gastroenterological association technical review on the diagnosis and treatment of gastroparesis (2004)

  6. Gastrointestinal manifestations in systemic autoimmune diseases (2011)

  7. Risk of gastroparesis in subjects with type 1 and 2 diabetes in the general population (2012)

  8. Smooth-muscle myopathy in systemic lupus erythematosus presenting with intestinal pseudo-obstruction (2016)

  9. Effects of scleroderma antibodies and pooled human immunoglobulin on anal sphincter and colonic smooth muscle function (2012)

  10. Gastroparesis in Parkinson disease: Pathophysiology, and clinical management (2021)

  11. Gastroparesis in non-diabetics: Associated conditions and possible risk factors (2018)

  12. Is gastroparesis found more frequently in patients with cystic fibrosis? A systematic review (2016)

  13. Delayed gastric emptying: A novel gastrointestinal finding in Turner's syndrome. (1996)

  14. Esophagogastroduodenoscopy | NIH: National Library of Medicine

  15. Review article: The diagnosis and management of gastroparesis (2007)

Other sources:

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