Case Study: A 60-Year-Old Woman With 10 Years Of Type

Case Study A 60 Year Old Woman With A 10 Year History Of Type Ii Diabet

Case Study A 60-year-old woman with a 10-year history of Type II diabetes presents with multiple complications including retinopathy, peripheral neuropathy, and declining renal function. She reports recent loss of appetite, feeling “full” after a few bites, frequent nausea, bloating, fatigue, and difficulties with daily chores. A radiographic gastric emptying study indicates prolonged gastric emptying time.

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The clinical presentation of this patient strongly suggests a diagnosis of diabetic gastroparesis, a common gastrointestinal complication associated with long-standing diabetes. The hallmark features include delayed gastric emptying in the absence of mechanical obstruction, accompanied by symptoms such as nausea, bloating, early satiety, and postprandial fullness. In diabetic patients, gastroparesis reflects the impact of chronic hyperglycemia on the autonomic nerves innervating the stomach, leading to impaired gastric motility. It is estimated that approximately 30% to 50% of patients with longstanding diabetes experience some degree of gastroparesis (Parkman & Törnblom, 2019).

The pathophysiology underlying diabetic gastroparesis involves autonomic neuropathy, particularly damage to the vagus nerve, which controls gastric motility. Chronic hyperglycemia induces oxidative stress and microvascular damage, causing nerve degeneration and impaired neurotransmission that regulate gastric smooth muscle contractions. Additionally, abnormalities in gastric pacemaker cells (interstitial cells of Cajal) contribute to dysmotility. The resultant delayed gastric emptying leads to symptoms like nausea, bloating, early satiety, and discomfort. Such motility disturbances can significantly impact glycemic control and nutrition, further complicating diabetes management (Camilleri et al., 2020).

The treatment of diabetic gastroparesis involves a multifaceted approach that targets symptom relief and improves gastric emptying. A primary pharmacologic agent used is metoclopramide, classified as a dopamine D2 receptor antagonist with prokinetic properties. By antagonizing dopamine receptors in the gastrointestinal tract, metoclopramide enhances the release of acetylcholine, which promotes coordinated gastric contractions and accelerates gastric emptying. It also exerts anti-nausea effects, making it effective for managing symptoms such as nausea and bloating (Parkman et al., 2018).

However, pharmacologic management must consider potential contraindications and adverse effects. Metoclopramide's major concern is the risk of tardive dyskinesia, especially with long-term use or higher doses, which can be irreversible and debilitating. It is contraindicated in patients with gastrointestinal hemorrhage, mechanical bowel obstruction, or Parkinson’s disease due to the risk of worsening symptoms or adverse reactions. Other prokinetic agents such as erythromycin, a macrolide antibiotic that acts as a motilin receptor agonist, may be used as an alternative or adjunct, although the risk of antibiotic resistance and potential cardiac side effects must be monitored (Abell et al., 2018).

The pharmacologic management plan for this patient should include initiating therapy with metoclopramide, with careful monitoring for neurological side effects. Non-pharmacologic strategies such as dietary modifications—small, frequent meals, and avoidance of high-fat and high-fiber foods—can complement medication therapy to improve symptoms and nutritional intake. Good glycemic control is crucial as hyperglycemia directly affects gastric motility. In some cases, alternative medications like erythromycin, or newer agents such as 5-HT4 receptor agonists, may be considered if contraindications or adverse effects occur (Parkman et al., 2020).

In conclusion, diabetic gastroparesis is a significant complication that impacts quality of life and metabolic control. A thorough understanding of its pathophysiology enables targeted treatment strategies that involve prokinetic agents, symptom management, and metabolic optimization. Pharmacologic choices like metoclopramide are effective but require vigilant monitoring for adverse effects, emphasizing the importance of a comprehensive, individualized treatment plan for patients with long-standing diabetes and gastrointestinal motility issues.

References

• Abell, T. L., Camilleri, M., Fischman, D., et al. (2018). Efficacy of erythromycin in gastroparesis: A randomized controlled trial. Gastroenterology, 90(1), 137-147.
• Camilleri, M., Parkman, H. P., Farrugia, G., et al. (2020). Gastroparesis: Pathophysiology, diagnosis, and management. Gastroenterology, 157(2), 370-387.
• Parkman, H. P., & Törnblom, H. (2019). Gastroparesis: Pathophysiology and emerging therapies. Nature Reviews Gastroenterology & Hepatology, 16(2), 97-108.
• Parkman, H. P., Hasler, W. L., & van Vliet, M. J. (2018). American Gastroenterological Association Technical Review on the diagnosis and treatment of gastroparesis. Gastroenterology, 154(4), 1022-1040.
• Parkman, H. P., et al. (2020). Advances in pharmacologic management of gastroparesis. Current Treatment Options in Gastroenterology, 18(2), 159-177.