Treatment goals in patients with diabetic gastropathy mainly focus on improving symptoms and quality of life and ensuring adequate nutritional intake. A stepwise approach, as outlined in TABLE 4, can be followed, depending on the specific symptoms and severity of the disease. Treatment initially focuses on glycemic control and dietary modifications before instituting pharmacological modalities.
| Table 4: Stepwise Treatment Plan for Diabetic Gastropathy | |
| Steps | Treatment Modalities |
| Step 1 | Adequate glucose control; correct metabolic abnormalities such as ketosis, uremia, and hypokalemia; avoid drugs that can slow gastric emptying such as narcotics, anticholinergics, tricyclic antidepressants, and calcium-channel blockers. |
| Step 2 | Dietary modification: Low-residue, low-fat diet Small, frequent meals Supplement with liquid formulas |
| Step 3 | Monotherapy with antiemetic or prokinetic agents, or both |
| Step 4 | Combination pharmacotherapy (e.g., erythromycin + metoclopramide) |
| Step 5 | Supplement with liquid formulas: Jejunostomy tube Intravenous hyperalimentation |
Glucose Control: Adequate glucose control is vital but very difficult to maintain in this population. The goal of insulin therapy or the oral antidiabetic agents should be to maintain the plasma glucose level less than 200 mg/dL. Plasma levels less than 200 mg/dL have been associated with improved gastric myoelectrical activity and autonomic function. However, improved glycemic control does not always correlate well with improvement in the severity of symptoms.
Dietary Modification: Dietary changes are required in the management of these patients in many instances, due to the fact they are not able to tolerate the standard American Diabetes Association diets. Patients with diabetic gastropathy should have a diet that is low in fiber and digestible roughage, because there is an increased incidence of bezoar formation with these foods. They should also have a low-fat diet (<40 grams/day), since lipids slow gastric emptying rates. Small frequent meals, usually four to six times daily, should replace the regular three meals per day. The smaller meals will reduce the neuromuscular work of gastric emptying and will also result in a slower but steadier rate of delivery of nutrients into the small bowel for absorption. Replacing solid food with a liquid diet or even supplementing with a liquid diet will also assist in improving the symptoms in these patients.
For patients experiencing severe nausea and vomiting, Koch et al. describe a stepwise diet as a treatment approach. TABLE 5 lists various foods and the caloric requirements for patients who are experiencing nausea and vomiting due to diabetic gastropathy.
| Table 5: Nausea and Vomiting (Gastroparesis) Diet | ||
| Diet | Goal | Avoid |
| Step 1: Gatorade and bouillon For severe nausea and vomiting: • Small volume of liquids such as Gatorade and bouillon (i.e., salty, with some caloric content) to avoid dehydration • Multiple vitamin |
1,000-1,500 cc/day in multiple servings (e.g., 12 4-oz servings over 12-14 hr). Patients can sip 1-2 oz at a time to reach approximately 4 oz/hr. |
Citrus drinks of all kinds, highly sweetened drinks. |
| Step 2: Soups • Soup with noodles or rice and crackers • Peanut butter, cheese, and crackers in small amounts • Caramels or other chewy confections • Ingest above foods in at least 6 small-volume meals/day • Multiple vitamin |
Approximately 1,500 calories/day to avoid dehydration and maintain weight. | Creamy, milk-based liquids. |
| Step 3: Starches, chicken, fish: • Noodles, pastas, potatoes, rice, baked chicken breast, fish • Ingest solids in at least 6 small-volume pulpymeals/day • Multiple vitamin |
Common foods that patient finds interesting and satisfying and that evoke minimal nausea/vomiting symptoms | Fatty foods that delay gastric emptying; red meats and fresh vegetables that require considerable trituration; fibrous foods that promote formation of bezoars. |