Patterns:

• Dysphagia, aspiration, abdominal pain and bloating, especially after eating, slow gastric emptying, gastroesophageal reflux, constipation, diarrhea and “irritable bowel” symptoms, gallstones, dilated colon which can result in fecal impaction, megacolon and even perforation of the bowel; and anal incontinence.

• Elevated GGT, which is usually NOT an expression of a liver disease, is a common and early finding. However, liver steatosis and cholelithiasis are also common findings in DM2 and should be carefully monitored.

• Gastrointestinal dysmotility that frequently results in pseudo-obstruction and can lead to aspiration.

Symptoms:

• Problems with chewing or swallowing, drooling, gastroesophageal reflux, bloating, abdominal pain, frequency and characteristics of bowel movements, diarrhea and fecal incontinence. Careful history should be taken to differentiate oropharyngeal dysphagia from esophageal dysphagia. Esophageal dysphagia sometimes causes chest pain due to acid reflux from the stomach.

• Involuntary weight loss or weight gain; dysphonia or dysphagia that may indicate pharyngeal muscle weakness; frequent cough and recurrent broncho-pneumopathies that may indicate aspiration; abdominal pain on palpation (generally in, or in the area of, the gall bladder); and abdominal bloating during routine physical exams.

Diagnosis:

• Discuss the following tests with your doctor:

  • Screening guidelines for colon cancer that apply to the general population.

Treatment:

• If taking mexiletine, take with food to avoid dyspepsia and transient ‘dizzy feelings’. Food extends absorption and lowers the peak level in blood, and lessens the gastrointestinal side effects that can potentially occur with mexiletine.

• If symptoms persist, refer to gastroenterologist for proper examinations which can include among others: ALT, AST, GGT, abdomen ultrasound and in some cases endoscopic evaluations.

• Non-pharmacologic treatments for gastrointestinal symptoms:

  • High-fiber diet (15-20 grams per day) for diarrhea or constipation as first response. Increased fiber intake should be undertaken with increased water intake, with the exception of drinks that are high in caffeine and fructose.

  • Nutrition consultation for dysphagia, weight loss or weight gain, to assess nutritional adequacy.

  • Dysphagia therapy referral, including compensatory strategies and dietary modifications, for oral pharyngeal dysphagia.

• Potential pharmacologic treatment for gastrointestinal symptoms:

  • Loperamide (Imodium), for diarrhea.

  • Gentle laxatives (see below) for constipation. Oils should be avoided. If no response to the first- or second-line recommendations below, a referral to a gastrointestinal specialist for anal manometry should be considered:

    • First-line therapy recommendations: polyethylene glycol (Miralax), senna (Ex-Lax, Senokot), docusate (Colace) or lactulose (Cholac).

    • Second-line therapy recommendations: bisacodyl (Dulcolax, Correctol), lubiprostone (Amitiza) or linaclotide (Linzess).

    • Metoclopramide (Reglan) may be used to reduce the symptoms of gastroparesis, pseudo-obstruction and gastric reflux. Long-term use is not recommended because this drug can cause tardive dyskinesia.

    • If bacterial overgrowth is found on breath testing, treating with antibiotics may reduce diarrhea.

  • Enteral feeding (tube feeding) for severe dysphagia, for example, dysphagia that causes weight loss or recurring pneumonia, if required.