Richard K. Bernstein, MD, FACE, FACN, FACCWS
Part 1 Chapter 22
Anumber of times throughout this book, you’ve come across the terms “delayed stomach-emptying” and “gastroparesis.” As I explained in Chapter 2, elevated blood sugars for prolonged periods can impair the ability of nerves to function properly. It’s very common that the nerves that stimulate the muscular activity, enzyme secretion, and acid production essential to digestion function poorly in long-standing diabetes. These changes affect the stomach, the gut, or both. Dr. Richard McCullum, a noted authority on digestion, has said that if a diabetic has any other form of neuropathy (dry feet, reduced feeling in the toes, diminished reflexes, et cetera), he or she will also experience delayed or erratic digestion.
Slowed digestion can be fraught with unpleasant symptoms (rarely), or it may only be detectable when we review blood sugar profiles (commonly) or perform certain diagnostic tests. The picture is different for each of us. For more than twenty-five years, I suffered from many unpleasant symptoms myself. I eventually saw them taper off and vanish after thirteen years of essentially normal blood sugars. Some of the physical complaints possible (usually after meals) include burning along the midline of the chest (“heartburn”), belching, feeling full after a small meal (early satiety), bloating, nausea, vomiting, constipation, constipation alternating with diarrhea, cramps a few inches above the belly button, and an acid taste in the mouth.
GASTROPARESIS: CAUSES AND EFFECTS
Most of these symptoms, as well as effects upon blood sugar, relate to delayed stomach-emptying. This condition is called gastroparesis diabeticorum, which translates from the Latin as “weak stomach of diabetics.” It is believed that the major cause of this condition is neuropathy (nerve impairment) of the vagus nerve. This nerve mediates many of the autonomic or regulatory functions of the body, including heart rate and digestion. In men, neuropathy of the vagus nerve can also lead to difficulty in achieving penile erections. To understand the effects of gastroparesis, refer to Figure 22-1.
On the left is a representation of a normal stomach after a meal. The contents are emptying into the intestines, through the pylorus. The pyloric valve is wide open (relaxed). The lower esophageal sphincter (LES) is tightly closed, to prevent regurgitation of stomach contents. Not shown is the grinding and churning activity of the muscular walls of the normal stomach.
On the right is pictured a stomach with gastroparesis. The normal rhythmic motions of the stomach walls are absent. The pyloric valve is tightly closed, preventing the unloading of stomach contents. A tiny opening about the size of a pencil point may permit a small amount of fluid to dribble out. When the pyloric valve is in tight spasm, some of us can sometimes feel a sharp cramp above the belly button. Since the lower esophageal sphincter (LES in Figure 22-1) is relaxed or open, acidic stomach contents can back up into the esophagus (the tube that connects the throat to the stomach). This can cause a burning sensation along the midline of the chest, especially while the person is lying down. I have seen patients whose teeth were actually eroded over time by regurgitated stomach acid.
Because the stomach does not empty readily, one may feel full even after a small meal. In extreme cases, several meals accumulate and cause severe bloating. More commonly, however, you may have gastroparesis and not be aware of it. In mild cases, emptying may be slowed somewhat, but not enough to make you feel any different. Nevertheless, this can cause problems with blood sugar control. Consuming certain substances, such as tricyclic antidepressants, caffeine, fat, and alcohol, can further slow stomach-emptying and other digestive processes.
Some years ago, I received a letter from my friend Bob Anderson. His diabetic wife, Trish, who has since passed away, had been experiencing frequent loss of consciousness from severe hypoglycemia, caused by delayed digestion. His description of an endoscopic exam, when he was allowed to look through a flexible tube into Trish’s stomach and
gut, paints a graphic picture.
All this brings me to today’s endoscopy exam. I watched through the scope and for the first time, I now understand what you have been saying about diabetic gastroparesis. Not until I viewed the inside of the duodenum did I understand the catastrophic effect of 33 years of diabetes upon the internal organs. There was almost no muscle action apparent to move food out of the stomach. It appeared as a very relaxed smooth-sided tube instead of having muscular ridges ringing the passage. I suppose a picture is worth a thousand words. Diabetic neuropathy is more than a manifestation of a tilting gait, blindness, and other easily observable presentations; it wrecks the whole system. This you well know. I am learning.
We would like to thank the publisher Little Brown and Company and Dr. Richard K. Bernstein, for allowing us to provide excerpts from The Diabetes Diet.
Copyright © 2005 by Richard K. Bernstein, M.D. All rights reserved. No part of this book may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without permission in writing from the publisher, except by a reviewer who may quote brief passages in a review.
This book is not intended as a substitute for professional medical care. The reader should regularly consult a physician for all health-related problems and routine care.
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