Severe gastroparesis associated recurrent hypoglycemic unconsciousness in diabetic neuropathy

Abstract

The gastric emptying rate has a decisive role in the regulation of blood glucose in diabetic patients. In some cases the gastric hypomotility might result an insufficient glucose absorption leading to extreme metabolic instability. Here we describe the diagnostic and the therapeutic strategy of this motility disorder. A 45 years old man was admitted to the department of neurology with severe recurrent convulsions and transient unconsciousness. His pancreatic diabetes developed 10 years before when the head of the pancreas was removed due to a pseudocyst. As the neurological diagnostic procedures did not reveal any organic central nervous disorder and the glucose levels were unstable, he was transfered to our clinic. The careful analysis of the daily blood glucose profile revealed severe recurrent hypoglycemias after breakfast besides the gradual reduction of the pre-breakfast insulin. Although he did not have digestive symptoms, a scintigraphic gastric emptying was done. The half-time of gastric emptying (HTE) after breakfast was extremely long (HTE: 487.6min, normal range: ≤67.6min.). The cardiovascular reflex tests reflected a severe autonomic neuropathy (score: 8, normal range: ≤2), with a dominance of parasympathetic dysfunction. The subcutaneous blood glucose was measured via an inserted electrode on 6 consecutive days by the application of a continuous blood glucose measuring system (CGMS). On all of the 6 days the post-breakfast glucose was much lower than the fasting value and on 2 of the 6 days it fell down to the hypoglycemic range. Parenteral, later oral metoclopramid and alpha lipoic acid were administered with oral pancreatic enzyme substitution. The insulin treatment and the diet were also adjusted. 6 months later the patient was hypoglycemia- and symptom-free, the HTE was less longer (245.8min.), the CGMS did not reveal post-breakfast glucose lowering while the autonomic neuropathy remained severe (score: 10). Conclusions: The measurement of the gastric emptying might be a part of the differenzial diagnostics of newly appearing convulsive disorder in diabetic patients with long-term disease. The application of cardiovascular tests and a CGMS method strengthens the diagnostic accuracy. The treatment of gastric hypomotility, neuropathy and exocrine insufficiency ensures a stable metabolism and an improvement in quality of life.