Gatwick Park G.I. DEPT Dr.Timothy Leigh MA MD FRCP Spire Gatwick Park Wednesday 14 th December 2011.

Gatwick ParkG.I. DEPT

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.


Risk Factors

• Longstanding IDDM.

• Autonomic Neuropathy.

• Cardiovascular disease and peripheral neuropathy.

• Increased Age.

• Poor glucose control.Gatwick Park

G.I. DEPT

Autonomic Neuropathy

• Gastroparesis.

• Through Vagus nerve innervation.

• Diarrhoea.

• Constipation.

• Faecal Incontinence.Gatwick Park

G.I. DEPT

Clinical Manifestations

• 75% of Diabetics have recurrent GI symptoms.

• Abdominal pain, nausea and vomiting,

dysphagia, diarrhoea, constipation, faecal

incontinence.Gatwick Park

G.I. DEPT

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

G.I. DEPT

Upper GI Symptoms

• Vomiting

• Gastro-Oesophageal Reflux

• Abdominal Pain

• Gallstones


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.


Gastro-oesophageal Reflux

• Low resting tone of LOS.

• > 33% have symptoms of GORD.

• Asymptomatic GORD, sensory neuropathy.

• Infection. Candida oesophagitis.Gatwick Park

G.I. DEPT

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.


Gastric Dysmotility (Cont’d)

• Epigastric fullness.

• Post-prandial nausea and vomiting.

• Bloating. Abdominal pain (>90%).

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

G.I. DEPT

Gastric Dysmotility (Cont’d)

• Poor glucose control, Hypo/Hyperglycaemia.

• Early satiety.

• Hyperglycaemia further delays emptying.

• Combination with vomiting = Ketoacidosis.Gatwick Park

G.I. DEPT

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.


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

G.I. DEPT

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.


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.


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.


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.


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

G.I. DEPT

Diabetes and Diarrhoea (Cont’d)

• Bacterial Overgrowth. Minority respond to

broad-spectrum antibiotics.

• Association with coeliac disease. Especially

Type 1 diabetes. Affects 6-10%


Causes of Diarrhoea

• ? Malabsorption. Pancreatic, Coeliac.

• Bacterial overgrowth. Blind loops.

• Autonomic neuropathy.

• IBD.

• IBS (16% vs 7% in non-diabetics).


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

G.I. DEPT

Investigation of Diarrhoea (Cont’d)

• Colonoscopy to exclude IBD.

• Hydrogen Breath test. (bacterial overgrowth).

• Trial of antibiotics, pancreatic supplements.


Treatment of Diarrhoea

• Broad-spectrum antibiotics. Ciprofloxacin,

Metronidazole, Tetracyclines.

• Anti-diarrhoeals. Imodium, Loperamide,

Codeine etc.

• Bile acid binding resins. eg Colestyramine.Gatwick Park

G.I. DEPT

Treatment Of Diarrhoea (cont’d)

• Pancreatic enzyme supplements.

• Dietary manipulation. Exclusion diets,

Lactose-free, Gluten, eg Coeliac.

• Probiotics.

• Octreotide.Gatwick Park

G.I. DEPT

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

G.I. DEPT

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

G.I. DEPT

Capsule Endoscopy Images


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

G.I. DEPT

Lower GI Manifestations (Cont’d)

• Faecal Incontinence (Neuropathy)

• Affects resting tone of internal and

external sphincters.

• Associated with Diarrhoea.Gatwick Park

G.I. DEPT

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

G.I. DEPT

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

G.I. DEPT

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

G.I. DEPT

NAFLD


Fatty Liver Histology


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.


Haemochromatosis

• Association with diabetes.

• Progression to Cirrhosis if untreated.

• High incidence of HCC.


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

G.I. DEPT

Preparation for GI Procedures

• Risk of Hypoglycaemia when NBM.

• Reduce or decrease pm + am insulin dose.

• Brittle diabetics need a sliding scale.


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


Summary (Cont’d)

• Insulin-dependent Diabetes.

• Liver. Steatosis, Cirrhosis

• Ketoacidosis.

• Stomach. Haemorrhagic gastritis

• Pancreas. Abdominal Pain, Pancreatitis

• Bowel. Pain and ileusGatwick Park

G.I. DEPT

And Finally……….


Apologies to Mark Twain, but ……….

The reports of my disappearance have been greatly exaggerated.


Gatwick Park G.I. DEPT Dr.Timothy Leigh MA MD FRCP Spire Gatwick Park Wednesday 14 th December 2011.

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