This patient is suffering from gastroparesis/delayed gastric emptying. The initial treatment for this condition is diet modification to frequent, small meals that are low in fiber and fat.
Presenting symptoms of gastroparesis include nausea, vomiting, early satiety, postprandial fullness, as well as abdominal pain and bloating. Management of this condition should first include: stopping medications that exacerbate gastric stasis, improving blood glucose control, increasing liquids in the patient's diet, transitioning to smaller more frequent meals throughout the day, stopping the use of tobacco and alcohol, as well as decreasing the amount of insoluble fiber and fat in the patient's diet. If these preliminary medication treatment options fail, pharmacologic management can include prokinetic agents such as metoclopramide and erythromycin.
Shakil et al. review the gastrointestinal complications of diabetes and focus on gastroparesis. The diagnosis of diabetic gastroparesis is made when other potential causes are excluded and postprandial gastroparesis is confirmed by a gastric emptying scintigraphy study.
Homko et al. conducted a study of 12 patients over 4 days to assess the effect of dietary fat content and food consistency on gastroparesis symptoms. The patients were presented with a different meal type each day: solid and high-fat, liquid and high-fat, solid and low-fat, and liquid and low-fat. Patients then quantified their gastrointestinal symptoms after each meal. The authors found that symptom severity was as follows: (greatest symptoms) solid, high-fat > solid, low-fat > liquid, high-fat > liquid, low-fat (least symptoms).
Illustration A lists the wide range of conditions in the differential diagnosis of the cause of gastroparesis. Illustration B is a gastric emptying scintigraphy study with normal results, as evidenced by the rapid emptying of the stomach and appearance of tracer in the small bowel by 2 hours. Illustration C is a gastric emptying scintigraphy study in a patient with gastroparesis; note how the tracer does not disappear from the stomach and very little tracer appears distally in the small intestine.
Answers 2,3: Metoclopramide and erythromycin are pro-kinetic agents that are indicated for the treatment of gastroparesis; however, dietary modification should be attempted first before pursuing pharmacologic treatment.
Answer 4: A botox injection may expedite gastric emptying and therefore alleviate some of the symptoms of gastroparesis; however, non-pharmacologic measures and prokinetic medications should both be attempted before considering this management option.
Answer 5: TPN is only required in severe cases of gastroparesis, in which a patient is not able to obtain sufficient nutrition; this patient's symptoms are not severe nor frequent enough to warrant this nutritional support at this time.
Shakil A, Church RJ, Rao SS. Gastrointestinal complications of diabetes. Am Fam Physician. 2008 Jun 15;77(12):1697-702.
PMID:18619079 (Link to Abstract)
Homko CJ, Duffy F, Friedenberg FK, Boden G, Parkman HP. Effect of dietary fat and food consistency on gastroparesis symptoms in patients with gastroparesis. Neurogastroenterol Motil. 2015 Jan 19.
PMID:25600163 (Link to Abstract)