A Difficult Case: Severe gastroparesis diabeticorum in a young patient with insulin dependent diabetes

Case report

Abnormalities in autonomic function affecting the gastrointestinal tract can often be shown by quantitative testing but only a few diabetic patients experience symptomatic autonomic neuropathy of the gut. Occasionally patients have severe disabling symptoms that may be difficult to manage. We describe a 28 year old woman found to have insulin dependent diabetes mellitus in 1979 and who has currently been in hospital for almost a year with severe and resistant gastroparesis. In the years before her admission to this hospital she had been investigated elsewhere for nausea and vomiting and had been labelled as suffering from anorexia nervosa. Subclinical nausea had been present for several years, and the vomitus she produced was seen to contain food that she had consumed a few days earlier. The vomiting and nausea made it difficult to control her diabetes, and she was thought to have “brittle” diabetes because of the wild swings in her glycaemic control. She was diagnosed as having the nephrotic syndrome in the year before her arrival here, and renal biopsy confirmed that this was due to diabetic nephropathy. At that time her serum creatinine concentration was 137 μmol/l. She was first admitted for her current symptoms almost a year ago with a three day history of a severe exacerbation of her nausea and retching, although milder symptoms had been present long before.

There was some deterioration in her renal function with a serum creatinine concentration of 204 μmol/l and a 24 hour urinary protein concentration of 4.52 g/l. The possibility of gastroparesis diabeticorum was considered, and gastric emptying studies were performed with colloid porridge labelled with technetium-99m. This showed poor gastric contractions particularly at the gastric antrum, and transit of the radiolabelled meal into the pylorus was slowed. The half time of gastric emptying was over two hours, consistent with gastroparesis. A later repeated study of gastric emptying showed some improvement of peristalsis in the antral area but confirmed delayed gastric emptying consistent with gastroparesis. Oesophageal manometry studies showed normal motility over the distal section of the oesophagus with a reduction of contractions at the most proximal section, but this was not affecting propagation of contractions distally. Gastroscopy showed grade 2 oesophagitis with a few petechiae around the cardia presumed to be caused by her vomiting and a large amount of residue in the stomach. Biopsies of the gastric antrum showed normal gastric mucosa with no evidence of metaplasia, Helicobacter pylori, dysplasia, or neoplasia.

The symptoms of nausea and vomiting continued unremittingly. Every recommended drug regimen was tried2 (metoclopramide, erythromycin, domperidone, and cisapride), all without any notable benefit. Even some rather unusual combinations of drugs were tried, including a concoction anecdotally said to be effective, consisting of tincture of belladonna, co-magaldrox, and diphenhydramine. The latter suffered the fate of all previous attempts at medical control of the nausea with no real change from the state of continued nausea and vomiting. Her symptoms were noted to be worse during intercurrent illnesses such as infections and when she was hyperglycaemic. She also seemed to suffer a worsening of her symptoms when premenstrual.

In addition to gastroparesis diabeticorum, which she undoubtedly has, psychological factors may have contributed to the problem. The patient was seen on numerous occasions to be putting her fingers down her throat to assist retching. She claimed vomiting lessened her symptoms of nausea and abdominal bloating. After detailed psychiatric review, however, it was concluded that she did not suffer from a psychiatric eating disorder in addition to her gastroparesis.

Those for surgery …

Those in favour of surgery pointed out that this young patient has been in hospital for almost a year with no real change in her symptoms, and medical treatment seemed to have failed. They claimed that with her inability to eat any solid food and the persistent vomiting she has a poor prognosis. As radiological studies have shown normal function of the small bowel gastric emptying procedure may give her considerable relief of her symptoms and result in a reasonable quality of life.

Those against surgery …

Those opposing surgery pointed out that gastric emptying procedures may be associated with other problems, and the patient's overall quality of life may not be improved. They argued that there is no real evidence to indicate that bypass surgery would have much symptomatic benefit. The patient has now had this problem for at least a year and probably longer. Although current thinking is that most cases remit spontaneously in less time than this, she could still improve given more time.