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Dr.Timothy Leigh MA MD FRCP

Spire Gatwick ParkWednesday 14th December 2011

Associations Between GI and Diabetes

• Complications of diabetes resulting in GI side-

effects. eg Autonomic Neuropathy, Ischaemia.

• GI Diseases which can also cause diabetes.

eg Haemochromatosis, Pancreatitis.

• Side-effects of drugs used in diabetes. Gatwick ParkG.I. DEPT

GI Manifestations In Patients With Diabetes

• Upper GI. Nausea, Vomiting, GORD.

• Diarrhoea, Constipation.

• Malabsorption, Pancreatic Insufficiency.

• Liver Disease.

• Pancreatic Disease.

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Risk Factors

• Longstanding IDDM.

• Autonomic Neuropathy.

• Cardiovascular disease and peripheral neuropathy.

• Increased Age.

• Poor glucose control.Gatwick Park

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Autonomic Neuropathy

• Gastroparesis.

• Through Vagus nerve innervation.

• Diarrhoea.

• Constipation.

• Faecal Incontinence.Gatwick Park

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Clinical Manifestations

• 75% of Diabetics have recurrent GI symptoms.

• Abdominal pain, nausea and vomiting,

dysphagia, diarrhoea, constipation, faecal

incontinence.Gatwick Park

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Diabetes and the GI Tract

• Between 20 and 40% of diabetic patients

will develop dysfunction of autonomic

system and neuropathy.

• Affects, oesophageal, gastric, small bowel,

colonic, pancreatic, gall-bladder.Gatwick Park

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Upper GI Symptoms

• Vomiting

• Gastro-Oesophageal Reflux

• Abdominal Pain

• Gallstones

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Oesophageal Dysmotility

• Manometry studies show >75% of patients with

autonomic neuropathy have oesophageal

dysmotility.

• Associated with gastric dysmotility.

• Impaired peristalsis and 30% dysphagia.

• Tertiary contractions.

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Gastro-oesophageal Reflux

• Low resting tone of LOS.

• > 33% have symptoms of GORD.

• Asymptomatic GORD, sensory neuropathy.

• Infection. Candida oesophagitis.Gatwick Park

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Gastric Dysmotility

• Disordered gastric motility.

• Poor gastric emptying, pyloric spasm.

• Gastroparesis diabeticorum.

• 20-50% of diabetics. F > M.

• < 40% Type 1, < 30% Type 2.

• Vagal control of Motilin + Peptide Hormones.

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Gastric Dysmotility (Cont’d)

• Epigastric fullness.

• Post-prandial nausea and vomiting.

• Bloating. Abdominal pain (>90%).

• Delayed emptying, Solids > Liquids. Bezoars.Gatwick Park

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Gastric Dysmotility (Cont’d)

• Poor glucose control, Hypo/Hyperglycaemia.

• Early satiety.

• Hyperglycaemia further delays emptying.

• Combination with vomiting = Ketoacidosis.Gatwick Park

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Investigations for Dysmotility

• History and Examination: Splash. Exclude other

causes, eg Pyloric Stenosis, Small Bowel Obst’n.

Drugs, Anticholinergics, Tricyclics, Diazepam etc.

• Barium Studies. Dilated stomach, Fasting Residue

(>75%) poor emptying. 50% of contrast still

present after 30 mins. Poor and irregular

contractions.

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Investigations for Dysmotility (Cont’d)

• Nuclear Scan. Radiolabelled Scintigraphy.

(Normal T1/2 = 50 mins. > 35% at 4hrs = Severe)

• 3D Ultrasonography.

• Antro-pyloroduodenal manometry.Gatwick Park

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Treatment of Gastric Dysmotility

• Blood Glucose Control. (Catch 22)

• Pharmaceutical Causes. eg Anticholinergics.

• Correction of nutritional problems, eg Enteral

or parenteral feeding. K+ levels.

• Anti-emetics unhelpful. Gatwick ParkG.I. DEPT

Treatment of Gastric Dysmotility (Cont’d)

• Prokinetic drug Therapies.

• Gastric Pacing.

• Surgical Bypass.

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Prokinetic Drug Therapies

• Metaclopramide: 10 – 30 mg, 1 hr before food.

• Domperidone: 20 – 40 mg 1hr before food.

• Dopamine antagonists, increase gastric tone and

ACh release in myenteric plexus. Increased electro-

gastrographic frequency.

• Central vagal effect increases emptying.

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Prokinetics Drugs (cont’d)

• Erythromycin: 100 mg before food. Motilin agonist.

• Amitriptyline.

• Gastric neurostimulation or pacing. Not proven.

• Botulinum Toxin. Pyloric dysmotility. Gatwick ParkG.I. DEPT

Novel Drugs + Therapies

• Neurokinin receptor agonists. (Aprepitant).

• Motilin agonists. (Mitemcinal)

• Ghrelin Agonists. “Hunger” Hormone.

Released in Stomach. Stimulates motility +

Appetite. (TZP-101)

• Acupuncture.

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Neurostimulation

• Gastric pacing.

• Implanted laparoscopically.

• Direct neural stimulation of gastric

mucosa.

• Differing results of few studies. Gatwick ParkG.I. DEPT

Surgical Methods

• Gastric Bypass Procedure.

• Post surgical dumping syndrome.

• Diarrhoea.

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Gastritis and Gastric Atrophy

• Increased risk of gastritis despite lower gastric

acid levels.

• Increased upper GI gastric bleeds in

ketoacidosis.

• Association with autoimmune pernicious

anaemia and gastric atrophy / achlorhydria. Gatwick ParkG.I. DEPT

Diabetes and Diarrhoea

• > 30% Diabetics have diarrhoea.

• Strong association with autonomic

neuropathy. Reduced adrenergic stimulation

of water reabsorption.

• M > F.

• Steattorrhoea. Pancreatic insufficiency.

• 40% have faecal incontinence.Gatwick Park

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Diabetes and Diarrhoea (Cont’d)

• Bacterial Overgrowth. Minority respond to

broad-spectrum antibiotics.

• Association with coeliac disease. Especially

Type 1 diabetes. Affects 6-10%

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Causes of Diarrhoea

• ? Malabsorption. Pancreatic, Coeliac.

• Bacterial overgrowth. Blind loops.

• Autonomic neuropathy.

• IBD.

• IBS (16% vs 7% in non-diabetics).

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Causes of Diarrhoea (Cont’d)

• Bile acid malabsorption.

• Bacterial causes.

• Drugs. NSAID’s, PPI’s, Metformin.

• Idiopathic. Gatwick ParkG.I. DEPT

Investigation of Diarrhoea

• Routine Culture. Faecal calprotectin.

• 24 Hour Stool faecal fat.

• Coeliac serology and small bowel biopsy.

• Presence of autonomic neuropathy.Gatwick Park

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Investigation of Diarrhoea (Cont’d)

• Colonoscopy to exclude IBD.

• Hydrogen Breath test. (bacterial overgrowth).

• Trial of antibiotics, pancreatic supplements.

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Treatment of Diarrhoea

• Broad-spectrum antibiotics. Ciprofloxacin,

Metronidazole, Tetracyclines.

• Anti-diarrhoeals. Imodium, Loperamide,

Codeine etc.

• Bile acid binding resins. eg Colestyramine.Gatwick Park

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Treatment Of Diarrhoea (cont’d)

• Pancreatic enzyme supplements.

• Dietary manipulation. Exclusion diets,

Lactose-free, Gluten, eg Coeliac.

• Probiotics.

• Octreotide.Gatwick Park

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Wireless Capsule Endoscopy

• For Investigation of Small Bowel Disease.

• Pill camera takes 2-3 frames /sec.

• Battery Life up to 11 Hours.

• Bowel preparation for clear view.

• Can be placed endoscopically (gastroparesis).Gatwick Park

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Indications For Capsule Endoscopy

• Unexplained Fe def Anaemia.

• Occult or Overt GI bleeding. Angiodysplasia.

• Abdominal Pain ? Cause. NSAID Enteropathy

• Suspected Crohns Disease.

• Coeliac, Unresponsive or Refractory.Gatwick Park

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Capsule Endoscopy Images

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Coeliac Disease Coeliac Disease

Angiectasia Crohns Disease

Lower GI Manifestations

• Constipation or Diarrhoea.

• Abdominal Pains. Ischaemia, Radiculopathy or

neuropathic, Spasm.

• Ischaemic Colitis. Bleeding. Diarrhoea, Pain.

• Mesenteric Angina. Pain, Infarction.Gatwick Park

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Lower GI Manifestations (Cont’d)

• Faecal Incontinence (Neuropathy)

• Affects resting tone of internal and

external sphincters.

• Associated with Diarrhoea.Gatwick Park

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Pancreatic Disease

• Diabetes as primary or secondary disease.

• Acute pancreatitis twice as common in young

insulin-dependent diabetics.

• Chronic Pancreatitis.

• Steattorrhoea. Exocrine dysfunction.

• Increased risk of Pancreatic Cancer.Gatwick Park

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Hepatobiliary Disease in Diabetes

• Metabolic liver disease. NAFLD, NASH.

Affects up to 80% of Diabetics. 20% cirrhosis.

• Cholelithiasis. Differing results.

Cardiovascular Disease.

• Severe Infections (Cholecystitis, Cholangitis).

• Sclerosing Cholangitis.Gatwick Park

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Cryptogenic Cirrhosis

• Previously called Idiopathic cirrhosis.

• Consequence of NAFLD

• Can affect up to 70% of NIDDM.

• Progression through NASH, 20% progress.

• Cirrhosis and sequelae.Gatwick Park

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NAFLD

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Fatty Liver Histology

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Treatment Of NAFLD/NASH

• Lifestyle with weight loss and exercise.

• Bariatric Surgery.

• Pharmacotherapy. Metformin, Rosiglitazone,

Pioglitazone. Anti-oxidants, Vitamin E.

• Lipid lowering agents. Ezetimibe.

• Statins. Some benefit.

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Haemochromatosis

• Association with diabetes.

• Progression to Cirrhosis if untreated.

• High incidence of HCC.

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Side-Effects of Drugs Used In Diabetes

• Metformin. Anorexia, nausea, vomiting,

diarrhoea, abdominal pain.

• Sulphonyl Ureas. Nausea, Vomiting, Diarrhoea.

• Glitazones. Rosiglitazone, Pioglitazone.

GI Disturbance, Nausea, Diarrhoea.Gatwick Park

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Preparation for GI Procedures

• Risk of Hypoglycaemia when NBM.

• Reduce or decrease pm + am insulin dose.

• Brittle diabetics need a sliding scale.

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Summary

• Diabetic Autonomic Neuropathy.

• Oesophagus. Dysphagia, Candidiasis

• Stomach. Gastritis, gastroparesis,

• Small bowel. Diarrhoea, Malabsorption

• Pancreas. Pancreatitis, Steatorrhoea

• Gallbladder. Cholecystitis, Gallstones

• Colon. Constipation

• Rectum. Faecal Incontinence

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Summary (Cont’d)

• Insulin-dependent Diabetes.

• Liver. Steatosis, Cirrhosis

• Ketoacidosis.

• Stomach. Haemorrhagic gastritis

• Pancreas. Abdominal Pain, Pancreatitis

• Bowel. Pain and ileusGatwick Park

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And Finally……….

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Apologies to Mark Twain, but ……….

The reports of my disappearance have been greatly exaggerated.

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