Conservative treatment with alternative routes of drug administration

There seems little doubt that this unfortunate young person has unusually severe diabetic gastroparesis, a condition thought to be due to vagal denervation of the stomach. It is important, however, to identify and correct factors that may be aggravating the gastroparesis to cause such a difficult problem that required admission to hospital for one whole year.

Swings in blood sugar concentrations, in particular hyperglycaemia, and fluctuation in serum potassium concentrations, may slow gastric emptying. Also dietary fat is known to impair gastric motility. Certain drugs may worsen the situation. With severe gastric stasis, bezoar formation can lead to pyloric obstruction, and these can be dealt with at endoscopy. Eating disorders pose another problem and are most commonly seen in young diabetic patients with poor glycaemic control. Such patients have a high incidence of diabetic complications, and in particular, those with measurable weight loss may develop a severe painful neuropathy.1 This patient already has an established nephropathy, and detailed autonomic function tests, nerve conduction studies, and retinal examination would be important. Despite psychiatric assessment concluding an eating disorder was not present 12 months in hospital may lead to psychological problems that would be important and would need to be dealt with appropriately and sympathetically.

The patient needs to be observed on the main ward with accurate charting of liquid and solid intake, volume and content of vomitus, urine volume, and bowel habit. No details are given of body weight, which again needs accurate monitoring. Optimal glucose control is vital. Frequent small meals of low fibre and low fat content can be effective. A short trial of nasogastric suction to relieve abdominal distension with intravenous fluids would be worth while. The standard antiemetic/prokinetic drugs have been tried without success. We are not told of their route of administration, and problems with absorption have to be considered. If given orally they may be more effective in liquid rather than tablet form, but other forms of administration should be tried—intramuscular, intravenous, or by suppository. The role of antiemetics acting as serotonin (5-HT ₃) antagonists (for example, ondansetron) has not been evaluated in this setting but may be worth a trial. Erythromycin, a motilin receptor agonist, could be given intravenously initially as this route may be more effective than oral administration.2 Bethanechol, a cholinergic agonist, will stimulate gastric motility and would be worth trying.

Further options pose serious dilemmas for the doctor and patient. An elemental diet could be given directly into the small intestine through a nasojejunal or nasoduodenal tube initially and, if successful, through an endoscopic jejunostomy. Intravenous hyperalimentation and surgical intervention would be justified only as last resorts if there was progressive loss of weight despite all other treatment. The complication rates are high and the outcome of surgery is unpredictable.3