Diabetic gastroparesis, sometimes known as “diabetic stomach,” often develops slowly, but over time, its symptoms can become impossible to ignore as they begin to impact every part of your life. 

It’s estimated that up to 50 percent of people with diabetes may experience some level of gastroparesis during their lifetime. However, symptoms can vary widely from person to person, and the condition is often misdiagnosed.

A man clutching his stomach with digestive pain

Key Points:

  • Diabetic gastroparesis occurs when the stomach muscles don’t properly move food.
  • Symptoms can include vomiting, fullness after small meals, heartburn, and unexplained weight loss.
  • Treatment focuses on dietary changes, including smaller, softer meals, and medications to manage symptoms.
  • Blood sugar management can become more challenging due to unpredictable digestion. 
  • Continuous glucose monitors (CGMs) are often recommended to help track glucose fluctuations.

Table of Contents

What is diabetic gastroparesis?

Gastroparesis is a known complication of both type 1 and type 2 diabetes that affects your body’s ability to properly digest food. 

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) defines gastroparesis, also known as delayed gastric emptying, as a disorder that slows or stops the movement of food from the stomach to the small intestine, even though there is no blockage.

Diabetes-related gastroparesis usually develops due to high blood sugar levels damaging nerves throughout the body, including the vagus nerve, which is crucial for digestive function. 

As a report in Diabetes Spectrum, a journal of the American Diabetes Association (ADA), explains, elevated blood sugar levels lead to chemical changes in nerves and can damage the blood vessels responsible for supplying them with oxygen and nutrients.

When the stomach muscles are damaged, they can function poorly or, in more severe cases, stop working altogether. This makes it difficult for the stomach to move food through the digestive tract. 

If food stays in the stomach too long, bacterial overgrowth can occur, as the food ferments. 

The ADA also notes that food can harden into solid masses called bezoars, leading to nausea, vomiting, and potentially dangerous obstructions in the stomach. 

Larger bezoars can block food from entering the small intestine, which can become life-threatening if left untreated.

Gastroparesis in people with diabetes despite healthy blood sugar levels

Although gastroparesis is typically linked to high blood sugar levels, it can still develop in people with diabetes even when their A1c (a measure of glucose management over the previous 2 to 3 months) and blood sugar levels are within a healthy range. 

In such cases, diabetes complications often occur alongside other conditions, rather than in isolation.

For instance, someone may experience both gastroparesis and retinopathy (damage to the retina of the eye), or a combination of peripheral neuropathy and retinopathy.

The signs and symptoms of diabetic gastroparesis

The symptoms of gastroparesis go beyond typical digestive issues. Like many diabetes complications, gastroparesis develops gradually, so early signs might go unnoticed until they become severe enough to disrupt your daily life.

Symptoms of diabetic gastroparesis

Common symptoms reported by the ADA and NIDDK include:

  • Nausea after eating
  • Vomiting after eating
  • Feeling full after eating only a small amount
  • Mild to severe bloating after meals
  • Pain in the upper stomach (epigastric pain)
  • Gradual, unexplained weight loss
  • Loss of appetite
  • Erratic blood sugar levels after meals despite accurate insulin dosing
  • Heartburn or acid reflux
  • Frequent burping
  • Impaired absorption of oral medications
  • Stomach wall spasms and cramping

“It’s really important to discuss any distinct stomach or digestion issues with your healthcare team,” says Susan Weiner, MS, RDN, CDCES, CDN, FADCES, and 2015 AADE Diabetes Educator of the Year. “This may include chronic constipation, bloating, and recent unexplained spikes in your blood sugar levels.”

Weiner emphasizes the need for healthcare professionals to create an open and supportive environment for patients, as discussing digestive issues can be uncomfortable. 

Managing blood sugar, especially with gastroparesis, brings its own layer of frustration, so having a supportive healthcare team is crucial for effective treatment.

Things that worsen symptoms of gastroparesis

Several factors can worsen the symptoms of gastroparesis, including:

  • High-fiber foods
  • High-fat foods
  • Large meals
  • Stress, anxiety, or depression
  • Smoking cigarettes
  • Alcohol
  • Carbonated beverages (soda, seltzer, etc.)

Medications that can worsen symptoms of gastroparesis

It’s important to review any medications you take for other conditions with your doctor, as some may indirectly affect your digestive system and worsen gastroparesis symptoms. 

Be sure to inform any healthcare professional prescribing new medications that you have gastroparesis. Even medications used for asthma, such as inhalers, can impact your digestive system.

Medications that may worsen symptoms include:

  • Narcotics (e.g., codeine, hydrocodone, morphine, oxycodone, tapentadol)
  • Certain antidepressants
  • Some anticholinergics (medications that block nerve signals)
  • Medications used to treat an overactive bladder
  • Muscle relaxants
  • Symlin (generic name pramlintide), a diabetes medication

Complications of diabetic gastroparesis

When your body cannot properly digest food, various complications can develop, sometimes even before an official diagnosis of gastroparesis is made. These complications include:

  • Dehydration due to frequent vomiting
  • Malnutrition from poor absorption of nutrients
  • Difficulty managing blood sugar levels after meals
  • Low calorie intake or trouble getting enough calories
  • Bezoars (as highlighted above, solid masses of undigested food in the stomach)
  • Difficulty maintaining a healthy weight due to reduced food intake
  • Lower quality of life due to malnutrition, pain, and other symptoms

Laura’s story: My first symptoms

“My first symptoms started six years prior to my diagnosis,” Laura Marie told Diabetes Strong. Laura has lived with type 1 diabetes since 2002, when she was 16 years old. She was officially diagnosed with diabetic gastroparesis in 2014.

“My gastroparesis symptoms included nausea and vomiting. I often felt nauseous in the mornings and would vomit undigested food hours or even days after eating.”

As her condition progressed, Laura began to experience severe bloating, to the point where her clothing became uncomfortable by the end of each day. Additionally, she suffered from intense cramping and pain in her stomach.

“My blood sugar levels were also incredibly erratic. I would have low blood sugar right after eating, followed by high blood sugar hours later, especially during the night.”

By using a continuous glucose monitor (CGM), Laura could track these erratic blood sugar patterns, which gave her valuable insight into how her condition affected her overnight levels.

The scariest aspect of her symptoms, however, was the frequent visits to the emergency room for diabetic ketoacidosis (DKA). Laura was hospitalized roughly every 6 months due to unmanageable blood sugars leading to DKA.

“It felt like the hundredth time I was in DKA when I finally became so burnt-out, frustrated, and scared. I told my healthcare team that I was desperate for tests and a diagnosis.”

Although Laura had previously asked to be tested for diabetic gastroparesis, her doctor had dismissed her concerns, saying she was “too young” for complications. 

Ultimately, her history of autonomic neuropathy (damage to the nerves that control body systems) made her a strong candidate for gastroparesis testing.

Diagnosing diabetic gastroparesis

There are several ways to test for and diagnose diabetic gastroparesis. 

Before performing any complicated procedures, your doctor will typically start with simple assessments of your overall health, which can indicate the need for further testing. These initial assessments may include:

  • Feeling your stomach for tenderness, hardness, or pain
  • Using a stethoscope to listen for unusual sounds in your stomach
  • Checking your blood pressure, temperature, and heart rate
  • Looking for signs of malnutrition and dehydration (which may involve blood tests)

Once these basic assessments are complete, the next step is to determine how quickly your stomach digests food and empties into your intestines. The NIDDK lists the following tests as current methods for diagnosing gastroparesis:

Barium X-ray

You will be asked to fast for 12 hours and then drink a thick liquid containing barium, which coats the inside of your stomach and makes it visible on an X-ray. 

A healthy stomach should empty completely after 12 hours. If food remnants are still visible, it’s a clear indication that your stomach is not emptying properly.

However, an empty stomach on the X-ray does not necessarily rule out gastroparesis. If symptoms persist, you may be asked to repeat the test, as delayed emptying can vary from day to day. 

You might also be asked to eat a barium meal, known as the “barium beefsteak,” which is more effective for diagnosing gastroparesis than the liquid test, as solids are more difficult to digest.

Radioisotope gastric-emptying scan (scintigraphy)

In this test, you will eat a meal containing a radioactive substance called a radioisotope. Afterward, you will lie under a machine that tracks how quickly the food moves through your digestive system. 

If more than half of the food is still in your stomach after 2 hours, this indicates gastroparesis.

Gastric emptying breath test

In this test, you will consume a meal containing a substance that eventually passes into your intestines and back into your breath. 

After 4 hours, a breath sample will be taken to assess how much of the substance is still present, which reveals the rate at which your stomach is emptying.

Gastric manometry test

For this test, you will eat a normal meal, and while sedated, a thin tube will be passed down your throat into your stomach. 

The tube will measure the muscular activity of your stomach to determine how well it is digesting food. Delayed digestion will be indicated by abnormal activity on the test.

The “SmartPill” or wireless motility capsule

In this innovative test, you will swallow a small electronic capsule that passes through your entire digestive tract. The capsule sends data to a device in your pocket, which tracks the speed at which food moves through your digestive system. 

Eventually, you will pass the capsule naturally during a bowel movement.

Other diagnostic tests to rule out other conditions

To ensure that your symptoms aren’t caused by another condition, your doctor may also recommend the following tests:

Upper endoscopy

While sedated, a thin tube (endoscope) will be passed through your throat into your stomach to check for other potential issues.

Ultrasound

This non-invasive test uses sound waves to create images of your stomach and nearby organs, helping to rule out conditions like gallbladder disease or pancreatitis.

Treatment for diabetic gastroparesis

One of the most challenging aspects of managing gastroparesis is adjusting what and how you eat. The NIDDK suggests the following dietary guidelines to help reduce symptoms and improve comfort:

  • Eat a low-fiber diet
  • Eat a low-fat diet
  • Eat smaller, more frequent meals (5 to 6 per day) instead of 2 to 3 larger meals
  • Chew food thoroughly and slowly
  • Opt for softer, well-cooked foods rather than hard or raw foods
  • Choose non-carbonated beverages
  • Limit or avoid alcohol
  • Drink plenty of water and healthy fluids like low-fat broth
  • Choose vegetable juices that are low in fiber and without added sugars
  • Drink low-sugar sports drinks with electrolytes
  • Take short walks after meals
  • Avoid lying down within 2 hours after eating
  • Take a daily multivitamin with meals

Following these recommendations can help manage symptoms, but it can also be frustrating. 

For example, low-fiber diets are crucial because fiber can be hard for your stomach to process. However, this can make it difficult to get enough fruits and vegetables. 

Similarly, small, frequent meals are easier to digest but may require more planning and preparation.

Weiner points out that every person’s experience with gastroparesis is different, so while some of these guidelines may work for you, others might not be necessary. It will take time and adjustment to find the right nutritional approach.

Eating slowly and chewing thoroughly is a universal recommendation that benefits nearly everyone. Cooking vegetables instead of eating them raw can also ease digestion. For instance, carrots are much easier on the stomach when cooked rather than eaten raw.

However, drinking liquids can sometimes fill up your stomach too quickly, which can be problematic if you struggle with constipation or limited stomach capacity. 

To balance hydration and nutrition, Weiner recommends drinking liquids between meals rather than during them.

Smoothies can be a helpful solution because they break down fruits and vegetables into small, manageable pieces for easier digestion. But keep in mind that blending fruits can also concentrate sugars, so it’s important to choose low-sugar options.

Medications to treat diabetic gastroparesis

Unfortunately, there is no single medication that works for everyone with diabetic gastroparesis. Treatment often involves a lot of trial and error, and even when a medication is effective, it may only provide relief for a short time.

One medication that some people find helpful is domperidone, which is available by prescription in countries like Canada but is not approved by the U.S. Food and Drug Administration (FDA) in the United States. 

People in the U.S. may be able to access this drug through certain online pharmacies or with special approval. 

While some report significant improvement, others, like Laura, find that its effectiveness wanes after a few days due to side effects.

Due to the variability in responses, working closely with a healthcare provider to find the right treatment is crucial. 

For a more extensive list of medications used to treat gastroparesis, you can refer to studies like this one in the journal Clinical Therapeutics.

Experimental treatments under study

Researchers are continually exploring new medications and procedures to improve treatment for gastroparesis.

One promising medication currently under development is called relamorelin. In phase 2 clinical research, this drug demonstrated the ability to speed up gastric emptying and reduce vomiting episodes. 

While relamorelin has not yet been approved by the FDA, further research is ongoing to evaluate its effectiveness.

In addition to medications, researchers are investigating novel therapies involving a slim tube known as an endoscope, which is inserted into the esophagus.

A procedure known as endoscopic pyloromyotomy, or gastric peroral endoscopic myotomy (G-POEM), is also being studied. 

This procedure involves cutting the pylorus, the muscular valve between the stomach and small intestine, to create a clearer pathway for food to pass through. 

Early results are promising for people with gastroparesis, though additional research is required to confirm its long-term effectiveness.

Laura’s story: Managing my nutrition around gastroparesis

“My diet is still my biggest struggle,” Laura shares. “Sometimes, I can eat anything without any digestion issues. But other times, the same foods make me feel lethargic, nauseous, in pain, and even depressed.”

Laura explains that, despite her efforts to identify patterns in what triggers her symptoms, nothing consistent has emerged. 

“One day, fruits and vegetables cause no problems, and the next day, they’re a complete disaster. My relationship with food has changed dramatically since being diagnosed with gastroparesis.”

Because of these challenges, Laura avoids eating out at restaurants or attending many social gatherings, uncertain of when pain, nausea, or vomiting might strike. “If I’m feeling unwell, I skip meals or avoid eating all day out of fear that eating something might trigger a flare-up.”

During severe or acute flare-ups, Laura often eats very little for several weeks until the symptoms subside. “When my appetite disappears, any attempt to eat just makes me nauseous. I lose weight quickly and become dehydrated.”

The unpredictability of how her stomach will react to any type of food — let alone common triggers — is, without a doubt, the most frustrating part for her of living with gastroparesis.

Surgical treatment methods for severe diabetic gastroparesis

In severe cases of gastroparesis, alternative food-delivery methods may become necessary to ensure you receive adequate calories and nutrients, according to the NIDDK. Although these options may seem overwhelming, some are less invasive than others.

Feeding tubes

In this procedure, while you are sedated, a doctor places a tube through your mouth or nose, extending into your small intestine. 

You’ll be on a liquid diet, and the feeding tube bypasses your stomach entirely, allowing nutrients to go directly into the small intestine. There are two types of feeding tubes to discuss with your healthcare team:

  • Traditional oral or nasal feeding tube (short-term)
  • Jejunostomy feeding tube (long-term)

Intravenous nutrition (parenteral nutrition)

Parenteral nutrition is another method for delivering nutrients without using the stomach. This involves a short-term intravenous solution that delivers liquid calories and nutrients directly into your bloodstream.

Venting gastrostomy

This procedure is designed to relieve pressure in the stomach. A small opening is created on the side of your abdomen and into your stomach.

 A tube is placed through this opening, allowing stomach contents to drain into an external device. This can help relieve severe stomach pain and pressure.

Gastric electrical stimulation (GES)

GES is a surgical option specifically for diabetes-related gastroparesis. A small, battery-powered device is implanted under the skin of your lower abdomen. It sends tiny electrical pulses to the nerves and muscles in your stomach, encouraging movement and digestion. 

This method can be used as a long-term treatment for severe nausea and vomiting in people who haven’t responded to other medications or treatments.

Managing diabetes differently with gastroparesis

One of the biggest challenges in managing blood sugar with gastroparesis is the unpredictability of digestion. You never quite know when the food you’ve eaten will be fully digested and absorbed into your bloodstream, affecting your blood sugar levels. 

On some days, meals may digest normally, while on other days, digestion slows unpredictably, making it nearly impossible to time your insulin doses accurately.

A CGM is one of the most helpful tools for managing this. A diagnosis of diabetic gastroparesis should qualify you for health insurance coverage for a CGM, so make sure your doctor emphasizes this diagnosis in your paperwork.

Laura’s story: Managing blood sugars with gastroparesis

Laura’s experience with gastroparesis has led to severe blood sugar fluctuations. 

“I often have low blood sugars after eating because the insulin kicks in before my food has been digested,” she explains. “Then, hours later, my blood sugar spikes, which can take a long time to come down, especially overnight.”

To manage this, Laura uses the multiwave bolus feature on her insulin pump, allowing her to take some insulin upfront and deliver the rest over the course of a few hours. 

“It’s complete guesswork to figure out how long my food will take to digest, which is why I use a Freestyle Libre to track my blood sugars,” she says.

While the Freestyle Libre isn’t a traditional CGM like the Dexcom or Medtronic, it still provides instant data whenever she scans the sensor, helping her catch blood sugar spikes. 

“If I notice a sharp rise, I take more insulin and monitor everything closely.”

However, preventing rapid spikes and managing correction doses is tricky. For anyone with type 1 diabetes, balancing carbs, insulin, and blood sugars can be challenging, but for those with gastroparesis, the unpredictable highs make it even more exhausting. 

“It’s an incredibly difficult balancing act, and without a CGM or the Freestyle Libre, I don’t think I could manage it.”

Laura’s advice to other people with gastroparesis

Laura strongly advises researching the condition independently, in addition to speaking with doctors. 

“I realized that many healthcare professionals don’t fully understand the condition, but I appreciated their honesty about it. Together, we’ve worked to manage it as best we can.”

She also encourages joining support groups or online forums to connect with others who are living with gastroparesis. 

“Patients really are the experts. They have countless tips and tricks to help make living with this difficult condition a bit more manageable.”

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