Clinical Evaluation Of Patients With Suspected Diabetic Enteropathy

The evaluation of upper GI symptoms in patients with diabetes by means of esophagogas-troduodenoscopy may document the presence of intercurrent conditions such as peptic ulceration, peptic stricture or Mallory-Weiss tears (a result of repeated retching and vomiting). The presence of bezoars suggests delayed gastric emptying.

Confirmation of the diagnosis of gastroparesis requires documentation of delayed gastric emptying. Scintigraphic transit studies are typically used to measure gastric emptying. However, it is important to emphasize measurements using labeled liquid meals are of limited value because gastric emptying may be normal even in the presence of significant symptoms. Assessment of solid emptying by means of a radiolabel that tags the solid phase of the meal is a more sensitive test with a well-defined normal range. The proportion of radioisotope retained in the stomach at 2 and 4 h distinguishes normal function from gastroparesis with a sensitivity of 90% and a specificity of 70% (59).

Another useful test for the measurement of solid phase gastric emptying utilizes a standardized meal with biscuit enriched with 13C, a substrate containing the stable isotope.

When metabolized, the proteins, carbohydrates and lipids of the S. platensis or the medium chain triglyceride octanoate give rise to respiratory CO2 that is enriched in13C. Measurement of 13CO2 breath content (a reflection of the amount of biscuit remaining in the stomach) by isotope ratio mass spectrometry allows estimation of gastric emptying t1/2 (60).

Gastropyloroduodenal manometry is a specialized technique that allows assessment of the pressure profiles in the stomach and small bowel. Hypomotility of the gastric antrum is an important cause of motor dysfunction and impaired emptying in diabetes. Patients with selective abnormalities of gastric function may be able to tolerate enteral feeding (delivered directly into the small bowel) whereas patients with a more generalized motility disorder may not be able to tolerate enteral feeding.

Gastric accommodation in response to meal ingestion may be impaired in diabetes. This may contribute to the GI symptoms of nausea, bloating and early satiety. Imaging of the stomach wall using 99mTc pertechnetate allows measurement of gastric volume after meal ingestion (Fig. 3) (61).

Diarrhea and fecal incontinence are often due the effects of diabetes on the GI tract. However, features suggestive of malabsorption such as anemia, macrocytosis or steatorrhea should lead to a consideration of underlying small bowel or pancreatic pathology. Celiac disease or bacterial overgrowth of the small intestine should be actively excluded (10).

Intestinal motor function can be evaluated by measurement of intestinal transit or rarely by small bowel manometry. Abnormal patterns of motility, however, are not reliable indicators of rapid or delayed intestinal transit. Scintigraphic methods that can simultaneously measure gastric, small bowel and colonic transit are accurate, noninvasive and relatively inexpensive.

Anorectal function can be evaluated by anorectal manometry that allows measurement of sphincter strength at rest (sympathetic function) and during squeeze (pudendal nerve function), testing of sensation to balloon distention. Anorectal ultrasound may help identify defects in the anal sphincter while a defecating proctogram allows evaluation of pelvic floor dysfunction or the functional significance of rectoceles or intussusception. However, most of these abnormalities can be successfully evaluated by careful rectal examination.

Diabetes 2

Diabetes 2

Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...

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