Endgames Case Review

Intractable nausea and vomiting associated with poor glycaemic control in a patient with type 1 diabetes

BMJ 2016; 354 doi: http://dx.doi.org/10.1136/bmj.i4197 (Published 17 August 2016) Cite this as: BMJ 2016;354:i4197
  1. S Gururaj Setty,, consultant diabetologist and endocrinologist1,
  2. Marie-France Kong,, consultant diabetologist2
  1. 1department of diabetes and endocrinology, Northampton General Hospital, Northampton, UK
  2. 2department of diabetes and endocrinology, University Hospitals of Leicester NHS Trust, Leicester, UK
  1. Correspondence to: S G Setty sowmyagururaj{at}doctors.org.uk

A 54 year old woman with type 1 diabetes was referred to the diabetes clinic with a four year history of nausea, early satiety, abdominal pain, and intermittent vomiting. In recent months she had experienced intractable nausea and vomiting, requiring frequent admission to hospital. Her glycaemic control was poor, with blood glucose readings in the high teens and frequent severe hypoglycaemic episodes after meals, when she needed help.

She has had diabetes for 45 years, complicated by diabetic retinopathy, peripheral neuropathy, and nephropathy. She has had chronic back pain and depression. She was taking insulin glulisine (quick acting insulin) 15 units with meals and insulin glargine (long acting insulin) 26 units at bedtime. Her other drugs included lansoprazole, atorvastatin, zopiclone, gabapentin, metoclopramide (short term), zomorph, and lactulose. She weighed 68.6 kg and her body mass index was 28 kg/m2. Her blood pressure was 129/78 mm Hg, with no postural drop. Her injection sites were normal and systemic examination unremarkable.

Her glycated haemoglobin (HbA1c) was 11.6% (103 mmol/mol), sodium 133 mmol/L (reference range 133-146), potassium 4.9 mmol/L (3.5-5.3), urea 12.3 mmol/L (2.5-7.8), creatinine 113 µmol/L (60-120), estimated glomerular filtration rate 65 mL/min/1.73 m2 (90-120), and blood glucose 19.3 mmol/L (3.3-6.0). Haemoglobin was 145 g/L (115-165), white cell count 12.1×109/L (4.0-11.0), and platelets 251×109/L (140-400). An upper gastrointestinal endoscopy six months ago found no obstruction or ulceration but showed residual food in the stomach after an eight hour fast (fig 1). An ultrasound scan of the abdomen was normal.

Fig 1 Gastric emptying curves

Questions

  1. What is the most likely diagnosis and how would you confirm this?

  2. How would you treat an acute presentation?

  3. How would you control symptoms in the long term?

1. What is the most likely diagnosis and how would you confirm this?

Short answer

Diabetic gastroparesis. Request fasting upper gastrointestinal endoscopy, coeliac screen, thyroid function …

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