Gatwick Park G.I. DEPT Dr.Timothy Leigh MA MD FRCP Spire Gatwick Park Wednesday 14 th December 2011.
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Transcript of Gatwick Park G.I. DEPT Dr.Timothy Leigh MA MD FRCP Spire Gatwick Park Wednesday 14 th December 2011.
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Gatwick ParkG.I. DEPT
Dr.Timothy Leigh MA MD FRCP
Spire Gatwick ParkWednesday 14th December 2011
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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
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GI Manifestations In Patients With Diabetes
• Upper GI. Nausea, Vomiting, GORD.
• Diarrhoea, Constipation.
• Malabsorption, Pancreatic Insufficiency.
• Liver Disease.
• Pancreatic Disease.
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Risk Factors
• Longstanding IDDM.
• Autonomic Neuropathy.
• Cardiovascular disease and peripheral neuropathy.
• Increased Age.
• Poor glucose control.Gatwick Park
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Autonomic Neuropathy
• Gastroparesis.
• Through Vagus nerve innervation.
• Diarrhoea.
• Constipation.
• Faecal Incontinence.Gatwick Park
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Clinical Manifestations
• 75% of Diabetics have recurrent GI symptoms.
• Abdominal pain, nausea and vomiting,
dysphagia, diarrhoea, constipation, faecal
incontinence.Gatwick Park
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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
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Upper GI Symptoms
• Vomiting
• Gastro-Oesophageal Reflux
• Abdominal Pain
• Gallstones
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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.
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Gastro-oesophageal Reflux
• Low resting tone of LOS.
• > 33% have symptoms of GORD.
• Asymptomatic GORD, sensory neuropathy.
• Infection. Candida oesophagitis.Gatwick Park
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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.
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Gastric Dysmotility (Cont’d)
• Epigastric fullness.
• Post-prandial nausea and vomiting.
• Bloating. Abdominal pain (>90%).
• Delayed emptying, Solids > Liquids. Bezoars.Gatwick Park
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Gastric Dysmotility (Cont’d)
• Poor glucose control, Hypo/Hyperglycaemia.
• Early satiety.
• Hyperglycaemia further delays emptying.
• Combination with vomiting = Ketoacidosis.Gatwick Park
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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.
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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
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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
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Treatment of Gastric Dysmotility (Cont’d)
• Prokinetic drug Therapies.
• Gastric Pacing.
• Surgical Bypass.
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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.
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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
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Novel Drugs + Therapies
• Neurokinin receptor agonists. (Aprepitant).
• Motilin agonists. (Mitemcinal)
• Ghrelin Agonists. “Hunger” Hormone.
Released in Stomach. Stimulates motility +
Appetite. (TZP-101)
• Acupuncture.
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Neurostimulation
• Gastric pacing.
• Implanted laparoscopically.
• Direct neural stimulation of gastric
mucosa.
• Differing results of few studies. Gatwick ParkG.I. DEPT
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Surgical Methods
• Gastric Bypass Procedure.
• Post surgical dumping syndrome.
• Diarrhoea.
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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
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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
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Diabetes and Diarrhoea (Cont’d)
• Bacterial Overgrowth. Minority respond to
broad-spectrum antibiotics.
• Association with coeliac disease. Especially
Type 1 diabetes. Affects 6-10%
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Causes of Diarrhoea
• ? Malabsorption. Pancreatic, Coeliac.
• Bacterial overgrowth. Blind loops.
• Autonomic neuropathy.
• IBD.
• IBS (16% vs 7% in non-diabetics).
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Causes of Diarrhoea (Cont’d)
• Bile acid malabsorption.
• Bacterial causes.
• Drugs. NSAID’s, PPI’s, Metformin.
• Idiopathic. Gatwick ParkG.I. DEPT
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Investigation of Diarrhoea
• Routine Culture. Faecal calprotectin.
• 24 Hour Stool faecal fat.
• Coeliac serology and small bowel biopsy.
• Presence of autonomic neuropathy.Gatwick Park
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Investigation of Diarrhoea (Cont’d)
• Colonoscopy to exclude IBD.
• Hydrogen Breath test. (bacterial overgrowth).
• Trial of antibiotics, pancreatic supplements.
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Treatment of Diarrhoea
• Broad-spectrum antibiotics. Ciprofloxacin,
Metronidazole, Tetracyclines.
• Anti-diarrhoeals. Imodium, Loperamide,
Codeine etc.
• Bile acid binding resins. eg Colestyramine.Gatwick Park
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Treatment Of Diarrhoea (cont’d)
• Pancreatic enzyme supplements.
• Dietary manipulation. Exclusion diets,
Lactose-free, Gluten, eg Coeliac.
• Probiotics.
• Octreotide.Gatwick Park
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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
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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
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Capsule Endoscopy Images
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Coeliac Disease Coeliac Disease
Angiectasia Crohns Disease
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Lower GI Manifestations
• Constipation or Diarrhoea.
• Abdominal Pains. Ischaemia, Radiculopathy or
neuropathic, Spasm.
• Ischaemic Colitis. Bleeding. Diarrhoea, Pain.
• Mesenteric Angina. Pain, Infarction.Gatwick Park
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Lower GI Manifestations (Cont’d)
• Faecal Incontinence (Neuropathy)
• Affects resting tone of internal and
external sphincters.
• Associated with Diarrhoea.Gatwick Park
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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
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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
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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
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NAFLD
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Fatty Liver Histology
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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.
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Haemochromatosis
• Association with diabetes.
• Progression to Cirrhosis if untreated.
• High incidence of HCC.
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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
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Preparation for GI Procedures
• Risk of Hypoglycaemia when NBM.
• Reduce or decrease pm + am insulin dose.
• Brittle diabetics need a sliding scale.
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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
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Summary (Cont’d)
• Insulin-dependent Diabetes.
• Liver. Steatosis, Cirrhosis
• Ketoacidosis.
• Stomach. Haemorrhagic gastritis
• Pancreas. Abdominal Pain, Pancreatitis
• Bowel. Pain and ileusGatwick Park
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And Finally……….
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Apologies to Mark Twain, but ……….
The reports of my disappearance have been greatly exaggerated.
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