A 65-year-old man comes to the office due to nausea, abdominal bloating, and early satiety for the past several months. He has had no heartburn or epigastric pain but does have occasional vomiting. The patient has a long-standing history of type 2 diabetes mellitus complicated by retinopathy, for which he takes basal-bolus insulin. Over the past 2 months, he has had several hypoglycemic episodes after meals despite decreases in premeal insulin dosage. Vital signs are within normal limits. On physical examination, the abdomen is soft and nontender with normal bowel sounds. Which of the following would be most helpful in treating this patient's condition?

Question

A 65-year-old man comes to the office due to nausea, abdominal bloating, and early satiety for the past several months.  He has had no heartburn or epigastric pain but does have occasional vomiting.  The patient has a long-standing history of type 2 diabetes mellitus complicated by retinopathy, for which he takes basal-bolus insulin.  Over the past 2 months, he has had several hypoglycemic episodes after meals despite decreases in premeal insulin dosage.  Vital signs are within normal limits.  On physical examination, the abdomen is soft and nontender with normal bowel sounds.  Which of the following would be most helpful in treating this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d3ad_75c8_bc81_431c1a194d49_MD0003_00 This patient's symptoms are suggestive of diabetic gastroparesis. Diabetic autonomic neuropathy due to chronic hyperglycemia can lead to esophageal motility disorders (eg, dysphagia), delayed gastric emptying (eg, gastroparesis), or intestinal dysfunction (eg, diarrhea, constipation, incontinence). Delayed gastric emptying is a result of uncoordinated smooth muscle contractions and ineffective peristalsis. Typical symptoms include nausea, vomiting, early satiety, and postprandial fullness. Due to delayed intestinal absorption of glucose, patients can have difficulty in timing insulin doses, leading to labile blood glucose and frequent hypoglycemia. Treatment of diabetic gastroparesis includes optimizing diabetes control; dietary modification (eg, smaller, more frequent meals, decreased fat and fiber intake); and medications to improve gastric emptying. Metoclopramide has both prokinetic and antiemetic properties and can relieve nausea, bloating, and postprandial fullness in diabetic gastroparesis. However, metoclopramide is associated with a small (<1%) risk of extrapyramidal side effects (eg, dystonia) and tardive dyskinesia (eg, involuntary movements). Alternate options include erythromycin, which has prokinetic effects; however, the effects diminish over time (tachyphylaxis) and it is generally used for only short periods (<4 weeks). (Choices A, F, and G) Antihistamines (eg, diphenhydramine, promethazine) and 5HT3 antagonists (eg, ondansetron) are antiemetic agents that can be used in combination with prokinetic agents to reduce vomiting in gastroparesis. However, they are less effective in promoting gastric motility and would not relieve the patient's other symptoms. (Choice B) Helicobacter pylori infection causes peptic ulcer disease, which can cause nausea and early satiety due to gastric outlet obstruction. However, most patients have significant upper abdominal pain, and H pylori eradication is not indicated prior to confirmatory testing. (Choices C and H) Proton pump inhibitors (eg, lansoprazole) or histamine H2 antagonists (eg, ranitidine) are helpful in symptomatic control of gastroesophageal reflux disease or erosive esophagitis, which more commonly presents with heartburn, regurgitation, and dysphagia. (Choice D) Progesterone analogs (eg, megestrol acetate, medroxyprogesterone acetate) are useful in the palliation of anorexia and in promoting weight gain in patients with cancer-related anorexia/cachexia syndrome. Educational objective: Diabetic gastroparesis (ie, delayed gastric emptying) presents with anorexia, nausea, vomiting, early satiety, postprandial fullness, and impaired glycemic control. Metoclopramide is a prokinetic agent that can relieve gastroparesis symptoms but is associated with a small risk of extrapyramidal side effects and tardive dyskinesia. References: Clinical guideline: management of gastroparesis. (http://www.ncbi.nlm.nih.gov/pubmed/23147521)

A 65-Year-Old Man Comes to the Office Due to Nausea