Diabetic gastroparesis can develop slowly, but eventually its symptoms become impossible to ignore as they will impact every part of your life.
It’s estimated that up to 50% of people living with diabetes develop some level of gastroparesis during their lifetime, but the symptoms can vary a lot from person to person and the condition is often not diagnosed correctly.
In this post, I will cover everything you need to know about diabetic gastroparesis: the symptoms, how it’s diagnosed, treatment options, daily management, and more. I will also share the best advice on dealing with diabetes gastroparesis from Laura, who lives with the condition, and Susan Weiner, the AADE Diabetes Educator of the Year.
What is diabetic gastroparesis?
Gastroparesis is a known complication of type 1 and type 2 diabetes that impacts your body’s ability to properly digest food.
“Gastroparesis, also called delayed gastric emptying, is a disorder that slows or stops the movement of food from your stomach to your small intestine, even though there is no blockage in the stomach or intestines,” explains the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).
Diabetes-related gastroparesis usually develops because high blood sugar levels damage nerves throughout the entire body, including the vagus nerve which plays a significant role in the function of the digestive tract.
“High blood glucose causes chemical changes in nerves and damages the blood vessels that carry oxygen and nutrients to the nerves,” explains the American Diabetes Association (ADA).
The result is that your stomach muscles simply work poorly, or in more severe cases, they may not work at all. This means that your stomach will have a very hard time digesting the food you eat and moving it properly through the digestive system from the stomach to the small intestines to the large intestines and eventually through your colon and anus.
“If food stays too long in the stomach, it can cause problems like bacterial overgrowth because the food has fermented,” explains the ADA. “Also, the food can harden into solid masses called bezoars that may cause nausea, vomiting, and obstruction in the stomach.”
The larger those solid masses of undigested food are, the more likely they could block food from passing into the small intestine. This can become dangerous quickly if ignored or left untreated.
Gastroparesis in people with diabetes despite healthy blood sugar levels
While it’s usually associated with high blood sugar levels, diabetic gastroparesis can sometimes develop even if your HbA1c is in a healthy range and blood sugars are in your goal range.
Generally, a person who develops complications of diabetes despite healthy blood sugar levels will experience a combination of conditions rather than just one. For example: gastroparesis and retinopathy, or peripheral neuropathy and retinopathy.
The signs & symptoms of diabetic gastroparesis
The symptoms of gastroparesis are much more complicated than straight-forward digestion troubles. And like any complication in diabetes, it develops gradually which means the earlier signs and symptoms may go unnoticed until they are severe enough and genuinely disrupting your overall wellbeing. Here are a variety of symptoms and triggers for symptoms as reported by the ADA and the NIDDK.
Symptoms of diabetic gastroparesis
- Nausea after eating
- Vomiting after eating
- Fullness after eating only a small amount
- Mild to severe bloating after eating
- Mild to severe pain in the “epigastric” or upper section of your stomach after eating
- Gradual and unexplained weight-loss
- Lack of appetite
- Erratic blood sugar levels after eating despite finely-tuned insulin doses
- Heartburn or acid reflux
- Frequent burping
- Impaired oral drug absorption
- Spasms and cramping of the stomach wall
“It’s really important to discuss any distinct stomach or digestion issues with your healthcare team,” says Susan Weiner, MS, RDN, CDE, CDN, FAADE and 2015 AADE Diabetes Educator of the Year. “This may include chronic constipation, bloating, and recent spikes in your blood sugar levels that you don’t understand or can’t explain with the usual everyday challenges of diabetes management.”
Weiner notes that she would hope any healthcare professional would create an open and non-judgmental environment for their patients because this can be a very uncomfortable situation for people with diabetes. Struggling with blood sugar management comes with its own inevitable layer of guilt and frustration, which means you need a healthcare team that can support you properly through a potential gastroparesis diagnosis.
Things that worsen symptoms of gastroparesis
- High-fiber foods
- High-fat foods
- Large meals
- Stress, anxiety or depression
- Smoking cigarettes
- Carbonated beverages (soda, seltzer, etc.)
Medications that can worsen symptoms of gastroparesis
It’s important to review any medication you’re taking for other health conditions with your doctor because they may indirectly affect your digestive system and worsen your gastroparesis symptoms. Whenever discussing taking a new medication with any healthcare professional, be sure to explain that you have gastroparesis. Even medications used for your asthma and inhaler can impact your digestive tract!
- Narcotics (codeine, hydrocodone, morphine, oxycodone, tapentadol, etc.)
- Some antidepressants
- Some anticholinergics (medications designed to block nerve signals)
- Some medications used to treat an overactive bladder
- Symlin (a diabetes drug, also known as pramlintide)
Complications of diabetic gastroparesis
When your body isn’t able to properly digest food, a variety of complications can develop–even before you’ve been properly diagnosed with gastroparesis.
- Dehydration due to frequent vomiting
- Malnutrition due to poor absorption of nutrients in the food you eat
- Difficulty managing your blood sugar levels after eating
- Low-calorie intake or difficulty getting enough calories
- Bezoars (solid masses of undigested food in your stomach)
- Difficulty maintaining a healthy weight due to inability to eat enough
- Overall lower quality of life due to malnutrition and pain
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. Her diabetic gastroparesis diagnosis was in 2014.
“My symptoms of gastroparesis included nausea and vomiting, often feeling nauseous in the mornings and vomiting undigested food hours or ever even days after I’d eaten it.”
Laura says she had gradually become incredibly bloated. The bloating was severe enough that her clothing felt remarkably uncomfortable by the end of each day. And on top of bloating, she had started experiencing severe cramping and pain in her stomach.
“My blood sugar levels also proved to be very erratic–I would have a low blood sugar after eating, and a high blood sugar hours later, especially throughout the night.”
By eventually wearing a Continuous Glucose Monitor (CGM), Laura says she could see the full evidence of her erratic overnight blood sugars.
The scariest part of her symptoms, though, was the increasingly frequent visits to the Emergency Room for DKA (diabetic ketoacidosis). Laura says she was usually admitted to the hospital about every 6 months because her unmanageable blood sugars would lead to DKA.
“It was after being in DKA for what seemed like the hundredth time that I became so burnt-out, frustrated, and scared, that I told my healthcare professionals I was desperate for tests and a diagnosis.”
Unfortunately, Laura had suggested she be tested for diabetic gastroparesis in the past, but her doctor dismissed her, telling her she was “too young” to experience diabetes complications.
The bigger picture, however, showed that she easily qualified for gastroparesis testing because she already had autonomic neuropathy indicators as well.
Diagnosing diabetic gastroparesis
There are several ways to test for and officially diagnose diabetic gastroparesis. Before performing any complicated tests or procedures, your doctor will (and should) do a few very simple assessments of your overall health that can indicate a need for further.
These simple assessments include:
- Feeling your stomach for any tenderness, hardness, and pain
- Use a stethoscope to listen for any unusual sounds in your stomach
- Checking your blood pressure, temperature, and heart rate
- Looking for common signs of malnutrition and dehydration (which can include blood tests)
The next steps are to look at how quickly your stomach is able to digest food and empty that food into your intestines. The ADA and NIDDK list the following tests as the current methods of testing for and diagnosis gastroparesis:
You’ll be asked to fast (not eat) for 12 hours, then you’ll drink a not-so-tasty thick drink that contains barium. The barium essentially covers the inside of your stomach so it can be seen clearly on an X-ray. A healthy stomach will empty completely if it’s been at least 12 hours since eating food. If your X-ray still shows remnants or food, that is a very clear indication that your stomach is not digesting and emptying properly.
However, an empty stomach doesn’t necessarily mean you don’t have gastroparesis. If you and your healthcare team still suspect gastroparesis, you may be asked to repeat the entire test (including the fasting) a second time a few days later simply because your stomachs delayed emptying can vary from day-to-day.
Be warned, you may also be asked to eat something called “the barium beefsteak” which is an entire meal containing barium versus just a liquid. Since liquids digest fairly easily in people with gastroparesis, the “beefsteak” version of the barium can be more helpful in testing for and diagnosis the condition.
Radioisotope Gastric-Emptying Scan (aka: scintigraphy)
Another no-so-pleasant meal, this test involves eating a food or meal that contains something called a “radioisotope.” This radioactive substance shows up scans, and it’s not dangerous or harmful. After eating the radioactive meal, you’ll lie under a machine that identifies the radioisotopes in that food and your doctor will be able to see just how quickly that food is digested. If more than half of the radioactive food is still in your stomach after two hours, it’s clear that you have gastroparesis.
Gastric Emptying Breath Test
This not-so-normal meal will contain a substance that eventually makes its way into your intestines, which is then passed back into your breath. Your doctor will then get a sample of your breath about 4 hours after eating to see how much of the substance is still present. This will reveal how quickly or slowly your stomach is digesting and emptying its contents.
Gastric Manometry Test
You don’t have to eat anything too funky in this one. Instead, you’ll eat a normal meal as directed by your doctor, then (while you’re sedated) your doctor will pass a very thin tube down your throat and into your stomach. The wire within the tube will measure the muscular activity of your stomach as its try to digest any liquids or foods in your stomach. Any delayed digestion due to gastroparesis will show up on this test.
The “SmartPill” or Wireless Motility Capsule
No funky foods here either. Instead, it feels a little futuristic: you’ll swallow a small electronic device that gradually moves through your entire digestive tract! The capsule sends data to a device kept in your pocket and eventually, your doctor will review that data to see how quickly or slowly your entire digestive tract (including the intestines) was able to digest that electronic little pill. Eventually, you will “naturally pass” the little pill during your next trip to the bathroom.
Your doctor may also perform these tests to rule out other conditions
It’s important to be sure that your digestive symptoms aren’t the result of something else, so your doctor may also perform an ultrasound or endoscopy of your stomach.
- Upper Endoscopy: This test requires you to be sedated just like the gastric manometry test mentioned earlier. Then your doctor will pass a long, thin tube (the endoscope) down your throat and into your stomach to look for any signs of other problems.
- Ultrasound: An ultrasound is painless and non-invasive. You’ll simply lie on down in your doctor’s office with your belly exposed while they use a handheld scan (the same kind used on a pregnant woman’s belly) to rule out things like gallbladder disease or pancreatitis.
Treatment for diabetic gastroparesis
The first, and perhaps most challenging, aspect of treating and managing gastroparesis is what and how you eat. The NIDDK recommends the following guidelines to reduce your symptoms and overall discomfort:
- Eat a low-fiber diet
- Eat a low-fat diet
- Eat small meals (5 or 6 a day) instead of 2 or 3 larger meals
- Chew your food thoroughly and slowly
- Eat softer, well-cooked foods versus hard or raw foods
- Choose beverages that are not carbonated
- Limit or completely avoid alcohol
- Drink plenty of water
- Drink plenty of healthy fluids like low-fat broth
- Vegetable juices low in fiber, without added sugars
- Low-sugar sports drinks containing electrolytes
- Taking walks after meals
- Avoid lying down within 2 hours after eating
- Take a daily multivitamin, with a meal — suggest a “whole-food” based vitamin which is gentler on your stomach
You may find yourself thinking, “How on earth will I get enough healthy vegetables and fruit if I’m supposed to avoid fiber?” It’s inevitably going to be frustrating that the nutrition advice you’ve heard your entire adult life is now going to cause you pain if you follow it.
“Gastroparesis and diabetes can certainly make eating a healthy diet even more challenging,” says Weiner.
Weiner emphasizes the fact that every patient’s experience of gastroparesis is different, which means that while some of these guidelines may be right for you, others may not be necessary. It will take time to carefully figure out the right approach to nutrition for you.
There are a few details, though, that Weiner says seem to help nearly every patient.
“I’d definitely recommend learning how to eat slowly if you don’t already, and chew your food thoroughly and completely,” says Weiner.
The more you cook your vegetables–and avoid hard, crunchy vegetables–the happier your stomach will likely be. This means choices like carrots, for example, should definitely be eaten only when cooked, never raw.
“Drinking liquids can also be a problem because they fill up your stomach space quickly,” explains Weiner. “If you’re struggling with constipation, that means you already have limited capacity in your stomach for a nutritious meal. Instead, try to drink liquids between meals in order to stay hydrated, including veggie smoothies!”
In fact, investing in a decent quality smoothie is probably a good idea simply because it ensures those vegetables and fruits are already broken down to tiny pieces, making it far less work for your stomach to break down.
Medications to treat diabetic gastroparesis
Unfortunately, there’s no one clear medication treatment path that seems to help everyone. There’s a great deal of trial and error, and even when you find something that works, it may only help with your symptoms for a few days.
To read an extensive list of medications used to help patients with gastroparesis, visit this study from Sweden‘s Sahlgrenska University Hospital.
A medication available by phone/mail-order in Canada that several gastroparesis patients shared as being very helpful is “domperidone,” but for those in the US, you’ll need to call this recommended online Canadian pharmacy: 1-866-930-3784.
While Laura reports that this drug only helps her for a few days before she has to stop taking it due to the side-effects, other patients describe it as a “game-changer.”
Laura’s story – Managing my nutrition around gastroparesis
“In terms of my diet, I find this is still my biggest struggle,” says Laura. “At times, I can eat anything I like and have no issues at all with digestion. But other times, food greatly affects me and leaves me feeling lethargic, nauseous, in pain, and at times, depressed.”
Laura says that while she’s tried to find patterns in what does or doesn’t make her symptoms worse, she hasn’t come up with anything helpful.
“Fruit and veggies can be no issue for me one day, and a complete disaster the next,” explains Laura. “I have also noticed that the way I think about food has changed a lot since being diagnosed with gastroparesis.”
The challenges of the condition have caused Laura to avoid eating out at restaurants or going to many social gatherings because she’s never sure if she’ll find herself experiencing pain, nausea, and vomiting shortly after eating.
“I also skip meals if I’m feeling unwell, or even avoid eating all day from fear of the repercussions of eating something that may cause a flare-up,” she explains, and justifiably so.
During more severe or acute flare-ups, Laura says she inevitably eats very little food for several weeks until things settle down.
“My appetite disappears completely, and anything I do to try and eat causes me to feel nauseous during those acute periods. I lose a lot of weight and become very dehydrated in a short amount of time.”
The inconsistency and unpredictable nature of how your stomach will react to any type of food, let alone the common triggers, is without a doubt its greatest challenge and source of frustration.
Surgical treatment methods for severe diabetic gastroparesis
In severe cases, the NIDDK says alternative food-delivery methods become inevitable to ensure you’re getting adequate calories and nutrients. While the idea sounds overwhelming and scary, some of these options are far less invasive than others.
Feeding Tubes: Essentially, while sedated, a doctor will put a tube into your mouth or nose that extends all the way into your small intestine. You’ll be placed on a liquid diet, and the feeding tube will allow those calories and nutrients to go directing into your small intestine, completely skipping the area with the most trouble: your stomach.
There are two types of feeding tubes to discuss with your healthcare team:
- a traditional oral or nasal feeding tube (short-term)
- Jejunostomy feeding tube (long-term)
Intravenous Nutrition: The last method of delivering adequate calories and nutrients without involving your stomach, is called Parenteral nutrition. Essentially, it’s a short-term intravenous solution that delivers liquid nutrients and calories directly into your bloodstream.
Venting Gastrostomy: This gadget is designed to relieve pressure inside your stomach by creating a very small opening on the side of your abdominal wall and then into your stomach. A tube is then placed through this opening, allowing stomach contents to flow out of the tube and into an external device that you attach to the tube when you need to relieve severe stomach pain.
Gastric Electrical Stimulation (GES): Used only in diabetes-related gastroparesis, this is a small, battery-powered device that sends very small electrical pulses to the nerves and muscles in your lower stomach, encouraging it to move and thus digest the food sitting in your gut. It’s placed by a surgeon just beneath the skin on your lower abdomen with wires from the device attaching to the muscles of your stomach.
This method can be used as a long-term treatment to help with severe nausea and vomiting in patients for whom other medications or treatments aren’t effective.
Managing diabetes differently with gastroparesis
The trickiest part of managing your blood sugars with gastroparesis is that you’re never quite sure when the food you ate is going to be fully digested and make its way into your bloodstream, eventually raising your blood sugar.
You’ll find that some meals–or entire days–digest normally while other days the food you eat will digest unpredictably slowly, impacting your blood sugar in a way that feels nearly impossible to accurately time your insulin doses around.
One of the most helpful tools for learning when to safely administer insulin for your meals is going to be a continuous glucose monitor (CGM). A diagnosis of diabetic gastroparesis should absolutely qualify you for health insurance coverage, just make sure your doctor emphasizes this diagnosis in the paperwork.
Laura’s story – Managing my blood sugars around gastroparesis
The most common pattern of otherwise irrational blood sugar fluctuations Laura experiences as a result of her gastroparesis are severe low blood sugars after eating because the insulin dose kicked-in but the food she ate wasn’t being digested.
“Then it causes very high sugars hours later, which take a long time to come down, especially throughout the night.”
One tactic she’s developed to manage this is by using the “multiwave bolus” on her insulin pump for meals.
“I take an upfront amount of insulin before I eat, and then have the pump deliver the rest of the dose over the course of a few hours,” explains Laura. “Trying to estimate how many hours it will take for my food to digest is complete guesswork though, which is why I use a Freestyle Libre to track my blood sugars.”
While the Freestyle Libre isn’t a continuous glucose monitor like a DexCom or Medtronic CGM, it still provides instant data every time she swipes the device over the sensor site on her body.
“If I see a sharp rise in my blood sugar, then I take more insulin and try my best to monitor everything.”
The tricky part is trying to prevent the fast spikes by taking a correction dose for a rising blood sugar but then hoping it doesn’t start to come down too quickly. While this is a challenge anyone with type 1 diabetes has when juggling carbs and insulin and high blood sugars, the frequency and unpredictable cause of those rapidly-rising highs make this a much more daunting and exhausting challenge for those with gastroparesis.
“It’s an incredibly difficult balance act, which I feel, without a CGM or something like the Freestyle Libre, is impossible to manage.”
Laura’s advice to other patients struggling with gastroparesis
First and foremost, Laura says it’s crucial to make sure you’re researching the condition yourself (rather than only taking direction and education from your doctors), and make sure you’re using credible sources when learning about potential treatments.
“I found that I had to accept that many healthcare professionals did not have a great understanding about the condition; however, I do appreciate their honesty in telling me this. And we have worked together to manage it as best we can.”
Laura absolutely recommends joining social media forums or support groups to talk to others about their own methods of managing the grueling symptoms of gastroparesis.
“The patients really are the experts, and they have many tricks up their sleeves to make living with this difficult condition more manageable.”
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