Interactive diabetes case 13: Deterioration of glycemia in a 59-year-old patient with type 2 diabetes complicated by retinopathy, nephropathy, and neuropathy – B3

ANSWER — 

Correct.

On further inquiry, you learn that the patient has had a "knot" in the left upper quadrant after meals for nearly a year. He experiences early satiety and has been eating multiple small meals and snacks as a result. He feels that food is "clogged up" in his abdomen for two to three days at a time. He vomits every few days. When he does so, the vomitus often contains food that he had eaten more than 24 hours earlier. Yesterday, the vomitus contained bits of chicken and salad from his supper the day before. He has a bowel movement every two to three days. His symptoms did not respond to either famotidine or omeprazole at full recommended doses for several weeks in each case. You conclude that the patient probably has diabetic gastroparesis.

What is your next step?

●You refer the patient to a gastroenterologist for endoscopic gastroscopy and injection of botulinum toxin in the pylorus. (See "Interactive diabetes case 13: Deterioration of glycemia in a 59-year-old patient with type 2 diabetes complicated by retinopathy, nephropathy, and neuropathy – C1".)

●You recommend a diet of multiple small meals, soft solids, and low fat without undigestible fiber. You prescribe metoclopramide liquid 2.5 mg by mouth four times a day 15 minutes before meals and at bedtime with plans to increase the dose up to 20 mg a day as needed and as tolerated. (See "Interactive diabetes case 13: Deterioration of glycemia in a 59-year-old patient with type 2 diabetes complicated by retinopathy, nephropathy, and neuropathy – C2".)

●You recommend a diet of multiple small meals, soft solids, and low fat without undigestible fiber. You prescribe metoclopramide liquid 10 mg by mouth four times a day, before meals and at bedtime. (See "Interactive diabetes case 13: Deterioration of glycemia in a 59-year-old patient with type 2 diabetes complicated by retinopathy, nephropathy, and neuropathy – C3".)

●You order a radiolabeled breath test using [13C]-acetate to confirm the diagnosis. (See "Interactive diabetes case 13: Deterioration of glycemia in a 59-year-old patient with type 2 diabetes complicated by retinopathy, nephropathy, and neuropathy – C4".)