Lower gastrointestinal symptoms are associated with worse glycemic control and quality of life in type 1 diabetes mellitus

Progression of Diabetic Kidney Disease and Gastrointestinal Symptoms in Patients with Type I Diabetes

(1) Background: Little research is conducted on the link between diabetic kidney disease (DKD) progression and diabetic gastroenteropathy in type 1 diabetes (T1D). (2) Methods. We performed a cross-sectional study with 100 T1D patients; 27 of them had progressive DKD, defined as an estimated glomerular filtration rate (eGFR) decline ≥3 mL/min/year or increased albuminuria stage, over a mean follow-up time of 5.89 ± 1.73 years. A newly developed score with 17 questions on gastrointestinal (GI) symptoms was used. Faecal calprotectin was measured by ELISA. Lower GI endoscopies were performed in 21 patients. (3) Results: The gastrointestinal symptom score demonstrated high reliability (Cronbach's α = 0.78). Patients with progressive DKD had higher GI symptom scores compared to those with stable DKD (p = 0.019). The former group demonstrated more frequent bowel movement disorders (p < 0.01). The scores correlated negatively with eGFR (r = -0.335; p = 0.001), positively with albuminuria (r = 0.245; p = 0.015), Hba1c (r = 0.305; p = 0.002), and diabetes duration (r = 0.251; p = 0.012). Faecal calprotectin levels did not differ between DKD groups significantly. The most commonly reported histopathological findings of enteric mucosa were infiltration with eosinophils, lymphocytes, plasmacytes, the presence of lymphoid follicles, and lymphoid aggregates. Conclusion: The progression of DKD is positively correlated with gastrointestinal symptoms; however, more research is needed to clarify the causal relationships of the gut-kidney axis in T1D.

What is the significance of a faecal elastase-1 level between 200 and 500μg/g?

Background

Pancreatic exocrine insufficiency is a cause of malabsorption. It is generally diagnosed if faecal elastase-1 (FE-1) levels are below 200 µg/g. Pancreatic function is assumed to be normal when faecal elastase levels are >500 µg/g. The significance of faecal elastase levels above 200 µg/g but less than 500 µg/g is unclear.

Methods

This retrospective study reports the response to treatment in patients who had an FE-1 level between 200 and 500 µg/g.

Results

Of these 82 patients, 28 were offered pancreatic enzyme replacement therapy (PERT). A clinical response, defined as an improvement in their initial symptoms after commencing PERT, was seen in 20 patients (71%), 7 with potentially predisposing conditions and 13 with functional diarrhoea. PERT particularly abolished or improved diarrhoea, steatorrhoea and flatulence.

Conclusion

Clinicians should, therefore, be aware that a trial of PERT given to patients with FE-1 levels between 200 and 500 µg/g may lead to improvement in gastrointestinal symptoms.

Novel insights into the pathogenic impact of diabetes on the gastrointestinal tract

Type 2 and type 1 diabetes are common endocrine disorders with a progressively increasing incidence worldwide. These chronic, systemic diseases have multiorgan implications, and the whole gastrointestinal (GI) tract represents a frequent target in terms of symptom appearance and interdependent pathophysiological mechanisms. Metabolic alterations linked with diabetic complications, neuropathy and disrupted hormone homeostasis can lead to upper and/or lower GI symptoms in up to 75% of diabetic patients, with multifactorial involvement of the oesophagus, stomach, upper and lower intestine, and of the gallbladder. On the other hand, altered gastrointestinal motility and/or secretions are able to affect glucose and lipid homeostasis in the short and long term. Finally, diabetes has been linked with increased cancer risk at different levels of the GI tract. The presence of GI symptoms and a comprehensive assessment of GI function should be carefully considered in the management of diabetic patients to avoid further complications and to ameliorate the quality of life. Additionally, the presence of gastrointestinal dysfunction should be adequately managed to improve metabolic homeostasis, the efficacy of antidiabetic treatments and secondary prevention strategies.

Gastrocolic Reflex Is Delayed and Diminished in Adults with Type 1 Diabetes

BACKGROUND

Constipation is a prevalent gastrointestinal complication in diabetes. The pathophysiology may include neural dysfunction and impaired gastrocolic reflex; however, investigation of the latter has been limited in diabetes. Using the wireless motility capsule, we investigated whether the gastrocolic reflex was impaired in adults with type 1 diabetes compared to healthy.

METHODS

One hundred and four adults with type 1 diabetes underwent investigation with the wireless motility capsule and recorded sleep cycle, eating habits, and bowel movements in a diary. Colonic motility index, contraction amplitudes, time-to-peak, peak motility, and colonic transit time were investigated directly in response to a meal. Diagnosis of peripheral (nerve conduction) and autonomic (orthostatic hypotension) polyneuropathy was verified.

RESULTS

In comparison with health, people with diabetes had at the time of ingestion decreased motility index and contraction amplitudes (p < 0.001), prolonged time-to-peak (p = 0.01), and borderline decreased peak motility (p = 0.06), which taken together indicate impaired coordination of the gastrocolic reflex. These features were most prominent in those with concomitant peripheral or autonomic neuropathy. Additionally, they were associated with prolonged colonic transit time (p > 0.01).

CONCLUSIONS

In type 1 diabetes, the gastrocolic reflex was delayed and diminished and further associated with the presence of neuropathy and constipation. These results suggest that impaired reflex is part of the underlying pathogenesis in the development of constipation.

Gastrointestinal Symptoms in Type 1 Diabetes: Relationship With Autoimmune and Microvascular Complications

PURPOSE

To assess reported rates of gastrointestinal (GI) symptoms and their association with autoimmune diseases and microvascular complications in adults and children with type 1 diabetes.

METHODS

The Gastrointestinal Symptom Scale was used to assess GI symptom type and severity in 2370 patients with type 1 diabetes aged 8 to 45 years evaluated as part of a clinical trial screening for celiac disease (CD). The presence and severity of GI symptoms and relationships with demographic, clinical, and other diabetes-related factors were evaluated.

RESULTS

Overall, 1368 adults (57.7%) aged 19 to 45 years and 1002 (42.3%) pediatric patients aged 8 to 18 years were studied. At least 1 GI symptom was reported in 34.1% of adults as compared with 21.7% of children (P < 0.0001). Common symptoms in children included upper and lower abdominal pain while adults more frequently reported lower GI symptoms. Participants with GI symptoms had higher hemoglobin A1c (HbA1c) levels (68 ± 14mmol/mol; 8.35 ± 1.37%) than those without symptoms (66 ± 15mmol/mol; 8.22 ± 1.40%; P = 0.041). Patients with microvascular complications (nephropathy, retinopathy, and/or neuropathy) were 1.8 times more likely to report GI symptoms (95% CI: 1.26-2.60; P < 0.01) after adjusting for age and sex. No association was observed between GI symptoms and the presence of autoimmune conditions, including thyroid and biopsy-confirmed CD (odds ratio = 1.1; 95% CI: 0.86-1.42; P = 0.45).

MAIN CONCLUSIONS

These results highlight that GI symptoms are an important clinical morbidity and are associated with increasing age, duration of type 1 diabetes, HbA1c, and microvascular complications but not with autoimmune comorbidities including CD.

Effects of probiotic Bifidobacterium bifidum G9-1 on the gastrointestinal symptoms of patients with type 2 diabetes mellitus treated with metformin: An open-label, single-arm, exploratory research trial

Aims/Introduction

Metformin is associated with the risk of gastrointestinal complications, and probiotic Bifidobacterium bifidum G9‐1 (BBG9‐1) can improve the symptoms of diarrhea. This study aimed to clarify the effects of probiotic BBG9‐1 on the gastrointestinal symptoms of type 2 diabetes mellitus patients using metformin.

Materials and methods

In this open‐label single‐arm exploratory study, 40 patients (mean age 64.0 ± 9.4 years) were given probiotic BBG9‐1 for 10 weeks. Changes in the gastrointestinal symptom rating scale total score, which was the primary end‐point, gastrointestinal symptom rating scale subscale scores, glycated hemoglobin levels and gut microbiota after the administration of probiotic BBG9‐1 were evaluated by the Student's t‐test.

Results

The gastrointestinal symptom rating scale total score significantly improved (from 2.02 ± 0.51 to 1.59 ± 0.43, change, −0.43 ± 0.49, P < 0.001). Furthermore, all gastrointestinal symptom rating scale subscale scores, including diarrhea (from 2.32 ± 1.14 to 1.89 ± 0.99, change, −0.42 ± 0.95, P = 0.007) and constipation (from 3.00 ± 1.16 to 2.20 ± 1.07, change, −0.80 ± 1.19, P < 0.001), scores also significantly improved. However, the glycated hemoglobin levels did not change (from 7.0 ± 0.7 to 7.0 ± 0.6%, change, 0.0 ± 0.4, P = 0.91). The relative abundance of the genus Sutterella decreased by the use of probiotic BBG9‐1 (from 0.011 ± 0.009 to 0.008 ± 0.006, change, −0.003 ± 0.006, P = 0.002).

Conclusions

Type 2 diabetes mellitus patients treated with metformin showed significant improvement in all gastrointestinal symptom rating scores after using probiotic BBG9‐1 without changing the glucose control. This study showed the potential usefulness of probiotic BBG9‐1 for improving gastrointestinal symptoms, including constipation and diarrhea, in type 2 diabetes mellitus patients treated with metformin.

Gastrointestinal symptoms and cardiac vagal tone in type 1 diabetes correlates with gut transit times and motility index

BACKGROUND

Although gastrointestinal (GI) symptoms are common in diabetes, they frequently do not correlate with measurable sensorimotor abnormalities. The wireless motility capsule (WMC) measures pressure, temperature, and pH as it traverses the GI tract wherefrom transit times and motility indices are derived. The aim was to investigate whether GI symptoms correlate with changes in (a) segmental transit times, (b) segmental motility index, (c) cardiac vagal tone, or (d) presence/absence of peripheral neuropathy in type 1 diabetes.

METHODS

Gastrointestinal symptoms in 104 participants with type 1 diabetes were measured using Gastroparesis Cardinal Symptoms Index and Gastrointestinal Symptom Rating Scale. All underwent standardized WMC investigation measuring segmental transit time and motility. Cardiac vagal tone and presence of peripheral neuropathy were measured using electrocardiographic and nerve conduction velocity testing.

KEY RESULTS

Colonic transit time was correlated with postprandial fullness (P = .01) and constipation (P = .03), while decreased colonic motility index was correlated with diarrhea (P = .01) and decreased bloating (P < .05). Symptoms were not correlated with gastric or small bowel transit time or motility index. In participants with low cardiac vagal tone, gastric motility index (P < .01) and colonic transit time (P < .05) were increased, but not in those with peripheral neuropathy. Abdominal pain was decreased with both peripheral neuropathy (P = .04) and decreased cardiac vagal tone (P = .02).

CONCLUSIONS AND INFERENCES

This study supports the rationale for whole gut investigation, using not only transit times but incorporating contractility indices as well. Furthermore, a decreased parasympathetic modulation and an increased hyposensate state appear to be present in type 1 diabetes.

Increased expression of hypoxia inducible factor-1 alpha and vascular endothelial growth factor is associated with diabetic gastroparesis

BACKGROUND

Gastroparesis is a recognized complication of diabetes but its pathogenic mechanism incompletely understood. Our aim was to determine whether HIF-1α and VEGF are secreted from gastric tissue is a fundamental factor that drives diabetic gastroparesis.

METHODS

Diabetes was induced in Sprague-Dawley by a single intraperitoneal injection of 65 mg/kg streptozotocin. After 4 and 12 weeks, rats were euthanized for assaying body weight, blood glucose, gastric acid secretion and gastric emptying. Morphologic changes in gastric mucosa were observed by the light microscope. Expression of HIF-1α and VEGF were assessed using immunohistochemistry, RT-PCR and Western blot analyses.

RESULTS

Compared with control group, blood glucose were significantly increased and body weight were markedly decreased in streptozotocin-induced diabetes. Gastric emptying was significantly decreased in diabetic rats compared to the control group at different times. The number of parietal cells was obviously decreased, and vacuolated degeneration in diabetic rats. Gastric acid secretion in diabetic group was significantly decreased, and expression of HIF-1α and VEGF were significantly increased in the diabetic group.

CONCLUSION

These results indicated that overexpression of HIF-1α and VEGF in the gastric mucosa and played a pivotal role in the progression of diabetic gastroparesis.

Pathophysiology and management of diabetic gastroenteropathy

Polyneuropathy is a common complication to diabetes. Neuropathies within the enteric nervous system are associated with gastroenteropathy and marked symptoms that severely reduce quality of life. Symptoms are pleomorphic but include nausea, vomiting, dysphagia, dyspepsia, pain, bloating, diarrhoea, constipation and faecal incontinence. The aims of this review are fourfold. First, to provide a summary of the pathophysiology underlying diabetic gastroenteropathy. Secondly to give an overview of the diagnostic methods. Thirdly, to provide clinicians with a focussed overview of current and future methods for pharmacological and nonpharmacological treatment modalities. Pharmacological management is categorised according to symptoms arising from the upper or lower gut as well as sensory dysfunctions. Dietary management is central to improvement of symptoms and is discussed in detail, and neuromodulatory treatment modalities and other emerging management strategies for diabetic gastroenteropathy are discussed. Finally, we propose a diagnostic/investigation algorithm that can be used to support multidisciplinary management.

Gastrointestinal symptoms in patients with diabetes mellitus and non-diabetic: A cross-sectional study in north of Iran

BACKGROUND AND AIM

Gastrointestinal (GI) symptoms are common in patients with diabetes mellitus (DM), which involved in high cost of health care and low quality of life. The aim of this study to investigate the prevalence of GI symptoms in diabetic patients referred to the Gastrointestinal and Liver Diseases Research Center (GLDRC), Guilan University of Medical Sciences (Rasht, Iran) using a validated questionnaire.

METHODS

In this descriptive, cross-sectional study, 255 diabetic patients and 255 non-diabetic subjects were recruited. Participants were randomly selected. The questionnaire recorded GI symptoms among the study population.

RESULTS

GI symptoms were reported in 91.4% of diabetic patients, and 42.1% of them were male. The common GI symptoms in diabetic patients were flatulence (33.0%), followed by retrosternal pain (14.9%), belching (13.7%), postprandial fullness (12.5%), and constipation (11.4%). Retrosternal pain, constipation, flatulence, loss of appetite, and abdominal distention were more prevalent in diabetic women than men.

CONCLUSIONS

DM is associated with high prevalence rate of upper and lower GI symptoms. This effect may be linked to gender and poor glycemic control in diabetic patients, but not to type and duration of diabetes.