Information on: Diabetics gastroparesis and more

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The diabetic esophagus: Comprehensive information related to heart burn and gastrointestinal reflux—its diagnosis and treatments including important information regarding anti-reflux surgery.

Introduction / Symptoms / Diagnosis / Treatments / Surgery and Fundoplication / Misc.

Introduction:

What is your esophagus?
Every time you swallow, you trigger a circular, rippling wave of muscular action that rolls out from the upper portion of the esophagus propelling the food contents downward to the stomach.

The esophagus is the hollow, flexible, mucous-lined, muscular tube that actively transports food into your stomach. This is why you can swallow while doing a headstand!

When masticated food, or liquid, reaches the end of your esophagus, a small, thick, ring- shaped muscle (called the lower esophageal sphincter, or LES) relaxes - ever so briefly - allowing for the passage of food into the upper part of the stomach (called the fundus)

This muscular action, known as "motility", is coordinated through a variety of chemical messengers as well as by nerves lying deep within layers of the esophagus (called enteric nerves) and nerves coming from the brain stem and spinal column (called the autonomic nerves)

Movement of food down your esophagus goes unnoticed. But, in general, the esophagus is exquisitely sensitive to any abnormal changes in motion (motility) or injuries / inflammation to its lining.

Tell me more about the diabetic esophagus and motility.
For many diabetics, problems with the esophagus are common.

Symptoms may be experienced such as:

• difficulty in swallowing (dysphagia),
• a feeling like a lump is stuck in your throat (globus),
• dull, burning pain behind your breast bone (heartburn),
• acid wash into your mouth (acid reflux), or
• food coming back up into your mouth (regurgitation).

The diabetic esophagus may have problems with weak propulsion of food (dysmotility); slow movement of food (delayed transit); altered sensations (hypersensitivity to even slight stomach acid exposures, which don't bother others); or even spasms (creating intense pain similar to the feeling of a heart attack, a.k.a. non-cardiac chest pain). Furthermore, problems created by a lax lower esophageal sphincter can leak stomach contents back up into the esophagus, creating the symptom of heartburn.

Diabetics with peripheral and/or autonomic neuropathies usually show a high rate of esophageal motor problems (dysmotility) whether they have symptoms or not.

High blood glucose levels interfere with normal gut motility.

Diabetic neuropathies also affect gut motility.

Neuropathies can be slowed or even reversed through maintaining tight blood glucose control.

Reducing excess body weight helps to reduce the problem of heartburn.

I feel like I have a constant lump in my throat. What is this?
Globus is the medical term that refers to a feeling of a persistent lump, tightness or feeling of strangulation in the throat. This sensation does not interfere with the swallowing of liquid or solid food.

This symptom is different from dysphagia (difficulty swallowing). Dysphagia too may be a "tight feeling" in the throat, but dysphagia is only elicited with swallowing food and is not a persistent feeling. Nor does stress make it worse. People describe dysphagia as food "hanging up" in their throat and the passage of food with each swallow is difficult.

The feeling of globus worsens with stress. Little is know about this symptom. Though very bothersome, it is not dangerous. Some physicians feel that GER and stress are at fault. Biofeedback, relaxation and stress-reduction techniques (such as yoga or focused, deep breathing and mental-imagery techniques), or distraction may help to relieve this symptom. Herbal teas, aromatherapy, even a warm, moist face cloth wrapped around the neck may be of great benefit in helping to relax the neck muscles.

What is GER/ GERD / NERD?
Acid reflux, or heartburn, is frequently in the news. No wonder, since it is the most common digestive symptom, affecting close to 10% of the North American population on a daily bases. Many experts feel that esophageal reflux is an esophageal motility problem.

Doctors call the problem GERD or gastroesophageal reflux disease. Disease denotes evidence of tissue damage to the lining of the esophagus. Not everyone with acid reflux has symptoms; and not everyone with symptoms shows evidence of any tissue damage.

The many facets of acid reflux:
Some individuals may have a very inflamed esophagus from reflux, but are spared any symptoms. Doctors don't fully understand this, and in some diabetics, neuropathies may actually dull the pain messages to the brain. Regardless, an inflamed esophagus needs treatment whether you are feeling any discomfort or not.

Esophageal tissue is vulnerable to burning from stomach acid and even to strong alkaline coming from the small intestine (duodenal reflux) and may develop inflammation, ulcerations (erosions), or healed ulcers resulting in scarring (strictures). These scars can narrow the passageway of the esophagus and make swallowing difficult.

To compound the picture further, some individuals may have acid reflux that produces symptoms, but not necessarily show any damage to the esophageal lining. This is usually called NERD, or non-erosive reflux disease; or simply called GER, gastroesophageal reflux.

Bottom line:

What is happening?
While hiatal hernias are a leading cause of reflux problems in the general public, and can occur in diabetics for the same reason, perhaps the leading cause of gastroesophageal reflux (GER) in the diabetic population is related to a motor disturbance of the gut. This gut motor problem may result secondarily to high blood glucose levels or the result of autonomic and/or peripheral neuropathy.

Therefore, interplay between motor problems in the stomach and esophagi are no doubt contributing to GER in many diabetics.

Not everyone with acid reflux problems gets improvement of their heartburn with acid-suppressing medications.
 

What is going on?
Scientific inquiry has focused on the lower esophageal sphincter (LES) as the culprit to reflux problems. Normally this circular muscle is tense. Like a cinch knot around a pouch, its job is to hold back the stomach contents, only relaxing at the front of an esophageal peristaltic wave, thus permitting entry to swallowed liquids or solids.

Yet, like everything else in the human body, the lower esophageal sphincter is beautifully complex, and our attempt to capture an understanding of what is going on usually falls short.

While a lax lower esophageal sphincter (LES) plays a role in the mechanics of reflux problems, the dynamics of the upper part of the stomach - called the fundus - may also become impaired through a failure to relax and to accommodate the food entering the stomach. This impairment may cause a postprandial (after-eating) reflux, early feeling of fullness, and discomfort or pain after eating.

As well, a motor (motility) disturbance in the lower region of the stomach (antrum) creates a delayed empting, resulting in a backup of food (stasis) and greatly contributing to reflux. Disordered motility often also extends to the upper part of the small bowel (duodenum), which adds to the back pressures as well as to the resistance to the passage of food, thus further delaying the emptying of the stomach.

Many investigators also fault disordered esophageal motility as a root cause for acid reflux. Therefore, acid suppression alone may not be sufficient to fully subdue symptoms of heartburn.

For the diabetic and for many others who suffer from GER, more research needs to be done in order to understand better the underlying motor disturbances that contribute to acid reflux, as well as to find medications to improve esophageal motility and stomach motor performance.