Abdominal Pain and Constipation in Diabetes Due to Dysmotility Syndrome

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.

A 58-year-old African American female (AAF) with a past medical history (PMH) of diabetes type 2 (DM2), diabetic gastroparesis, megacolon, autonomic neuropathy, was admitted to the hospital with a chief complaint (CC) of abdominal pain and constipation for 1 week.

The pain was located in the epigastrium and left lower quadrant (LLQ), rates as 6/10 on 0-10 scale, constant, and non-radiating.

The patient did not complain of nausea, vomiting or diarrhea (N/V/D), chest pain (CP) or shortness of breath (SOB). She was was admitted with similar complaints 3 weeks ago, white blood cell count (WBC) was 15 mm3, the temperature was 37.4 degrees Celsius (C). At that time, she was diagnosed with diverticulitis and discharged (D/C'd) home with an antibiotic course and Colace (docusate) and MiraLAX (polyethylene glycol).

Past medical history (PMH)

Diabetes type 2 (DM2), diabetic gastroparesis, megacolon, autonomic neuropathy, hypertension (HTN), carpal tunnel syndrome, peripheral neuropathy.

She had upper and lower endoscopies 2 months ago. Esophagogastroduodenoscopy (EGD): Gastroparesis, autonomic neuropathy. Colonoscopy: Megacolon, colonic inertia due to diabetes.

In addition, she also had a water-soluble barium enema and a CT of the abdomen, which did not show any diverticula.

Past surgical history (SH)

Cholecystectomy (laparoscopic), hysterectomy.

Medications

NPH insulin, Prevacid (lansoprazole), clonidine, Colace (docusate), Lopressor (metoprolol), Norvasc (amlodipine), lisinopril, tramadol (Ultram), Reglan (metoclopramide), MiraLAX (polyethylene glycol).

Physical examination

Obese lady in no apparent distress (NAD).
VS 36.9-18-66-168/68.
Abdomen: Soft, obese, +BS, epigastric and LLQ tenderness, no rebound.
Rectal examination: hemorrhoids, empty ampulla.

What is the most likely diagnosis?

Gastroparesis, megacolon and constipation.

Diverticulitis is unlikely - she had no diverticula on the imaging studies done recently. Pancreatitis is also not very high on the differential diagnosis list - she is just an occasional drinker and pancreatitis was "ruled out" just 2-3 weeks ago.

What laboratory workup would you suggest?

CBCD, CMP, INR/PTT, INR
CXR, KUB
UA, urine C&S

Laboratory results

WBC was increased to 15.4 mm3, neutrophils 64%, lymphocytes 18%.
CXR: Mild cardiomegaly, no infiltrates.
KUB: Fecal retention.
UA and urine culture: negative.

What do you think is the reason for the increased WBC? Is leukocytosis due to an infection?

An empiric therapy wtih Cipro (ciprofloxacin) and Flagyl (metronidazole) was already started on admission. Blood cultures (BCx) were negative, she had no fever and the repeated WBC the next day after the admission decreased to 9/mm3.

The most likely reason for leukocytosis in this patient is a stress reaction due to pain. She had a similar response during the previous admission, and she had no infectious focus at that time according to the ID consultant.

What happened?

A GI consult was called. The patient's pain decreased after she moved her bowels. Norvasc (amlodipine) was stopped because calcium channel blockers (CCBs) have an antimotility effect. Clonidine, which can be used as an antimotility agent in diabetic autonomic diarrhea, was also discontinued. The antibiotics and tramadol were stopped.

Her blood pressure (BP) was in the range of 130/80 mmHg and she was advised to follow-up with her primary care physician (PCP) for a BP check within a week.

The patient had no further complaints and was discharged (D/C'd) home.

What else can we do?

We started lactulose instead of Miralax as a prokinetic agent.

Erythromycin can be used as prokinetic but a study (NEJM 10/2004) showed a 2-5-fold increased risk of sudden cardiac death in patients taking erythromycin plus other antihypertensive medications.

A nuclear medicine gastric emptying scan was ordered to confirm the diagnosis of gastroparesis.

Final diagnosis

Abdominal pain and constipation due to diabetic gastroparesis and megacolon.

What did we learn from this case?

Leukocytosis can be due to a variety of reasons and not all of them are of infectious nature.

Autonomic neuropathy and GI dysmotility syndromes are well known complications of diabetes.

Recognize medications with antimotility effects and discontinue them, e.g. amlodipine (and other CCBs), clonidine and tramadol.

Twenty years after the diagnosis, 30-60% of DM patients develop signs of visceral neuropathy.

GI symptoms are significantly associated with autonomic and peripheral neuropathy (our patient had peripheral neuropathy with numbness, burning pain and was started on Neurontin during this hospital stay).

Incidence of peripheral neuropathy plus: constipation (29%), GERD (19%), dyspepsia (14%), and frequent abdominal pain (11%).

Diabetic gastroparesis is usually not progressive, does not increase mortality and does not improve with better metabolic control of diabetes.

References

Diabetes
UpToDate 12.3.
Gastroparesis. American Diabetes Association.

Published: 03/11/2005
Updated: 01/19/2012

6 comments:

  1. I have Abdominal Pain & Vomiting & Constipation going to have a gastric pace maker for 3 days. What can a gastric pace maker monitor while having for only a 3 days?

    ReplyDelete
  2. 1-Pt with significant PMHx of DM on Insulin. Why UA,
    Urine C&S was not Done. Did you R/O UTI. Diabetic Pt
    might present with elevated WBC without urinary tract symptoms.

    2-Her BP:168/68. You d/c Norvasc and Clonidine. What did you replace it with ?

    3-Why you did not d/c Tramadol which causes constipation.

    ReplyDelete
  3. The case was updated with additional information directly in the text above:

    UA and urine C&S were negative.

    BP was 130/80 after the pain resolved. F/U with PCP was scheduled within a week.

    Tramadol was stopped.

    ReplyDelete
  4. Once I saw a patient with a huge colon. He refused surgery on multiple occasions. He actually presented with a worsening shortness of breath partly because his colon was pushing on his diaphragm. You should see this, it's pretty cool:
    http://realicu.com/content/colonic-distention-megacolon

    ReplyDelete
  5. Ralph,

    Impressive pictures. Thanks for sharing.

    ReplyDelete