CASE

PRESENTATION
Konyang University Hospital
Department of Endocrinology
PK 15801053
Patient Information
•유O 홍
• F / 26

Chief Complaint
• Abdominal pain & vomiting for 2 days prior to admission
Present Illness
• Repeated END admission for Type 1 DM & complications (2010),
diagnosed for DM gastropathy in 2018 and admitted for
postprandial vomiting, watery diarrhea (3-4/day), heartburn
through ED without clinically significant diet change
Past History
• Medical History
• DM Type 1 (’03)
• DM nephropathy (’10)
• DM retinopathy (’15)
• DM neuropathy (’17)
• DM gastropathy (’17)

• Admission History
• 2010-2019 까지 17 차례 (END 15 차례 ) 입원
• Diabetic gastropathy
• 2017 년 4 차례 , 2018 년 6 차례 , 2019 1 차례
• Last admission: 2019-02-14~2019-02-23
• 2018-06-19 NM Scintigraphy found delayed gastric emptying
• Diabetic ketoacidosis (‘11, ‘15)
Past History
• Medication
• Diabetes
• SC
• Insulin degludec
• 트레시바 /22 단위 / 매일 아침 시전 / 내원전일 / 미지참
• Insulin aspart ( 둘 중 하나 )
• 노보래피드 /6-8 단위 / 매 식전 / 내원전일 / 미지참
• 피아스프 /5-6 단위 / 매 식전 / 내원전일 / 미지참
• Skipped on day of admission
Past History
• Family History
• Father – DM
• Mother – DM

• Social History
• Alcohol (-)
• Smoking (-)

• Allergy History
• None
Review of System
• General
• General weakness / Easy fatigue (+/+)
• Poor oral intake / Weight loss (+/+) - 5kg
• Fever / Chill / Sweating (+/-/-)
• Dizziness / Vertigo (-/-)
• Loss of consciousness (-)

• Skin
• Itching / Rash / Pigmentation / Pruritis (-/-/-/-)
• Respiratory
• Cough / Sputum / Hemoptysis / Grunting (-/-/-/-)
• Dyspnea / Tachypnea / Orthopnea (-/-/-)
Review of System
• Cardiovascular
• Chest pain / Palpitation (-/-)
• DOE / Syncope (-/-)

• Gastrointestinal
• Abdominal pain / Dyspepsia / Heartburn (+/+/+)
• Anorexia / Nausea / Vomiting (+/+/+)
• Diarrhea / Constipation / Tenesmus (+/-/-)
• Hematemesis / Melena / Hematochezia (-/-/-)
Review of System
• Genitourinary
• Hematuria / Dysuria / Foamy urine (-/-/-)
• Polyuria / Oliguria / Nocturia (-/+/-)
• Frequency / Urgency / Incontinence (-/-/-)
• Voiding difficulty / Urinary retention (-/-)

• Musculoskeletal
• Back pain / Flank pain / Joint pain / Join swelling (-/-/-/-)
• Muscle weakness / Atrophy / Loss of motion / Stiffness (-/-/-/-)

• Nervous
• Pain / Numbness / Stiffness / Swelling (-/-/-/-)
• Syncope / Seizure (-/-)
Review of System
HEENT
• Head • Neck
• Headache (-) • Lymph enlargement (-)
• Neck vein enlargement (-)
• Eyes
• • Palpable neck mass (-)
Impaired vision / Diplopia (-/-)
• Pain / Dryness / Tearing / Redness (-/-/-/-) • Mouth & throat
• Dryness / Sore throat (+/-)
• Ears
• • Swallowing difficulty (+)
Hearing difficulty (-)
• Foreign body sensation (+)
• Discharge / Tinnitus (-/-)
• Nose
• Obstruction / Dryness (-/-)
• Congestion / Discharge / Anosmia (-/-/-)
• Epistaxis (-)
Physical Examination
• Vital sign
• BP : 140/80mmHg HR : 100 회 /min RR : 20 회 /min BT : 37.8℃
• Physical
• Height : 164cm Weight : 48kg BMI : 18.9
• General appearance
• Acute ill looking
• Mental status
• Alert
Physical Examination
• Skin
• Rash/Dryness/Scar (-/-/-)
• Edema (-)
• Chest
• Clear breath sound
• Normal chest shape
• Symmetric expansion
• No retraction
• Heart
• Regular heart beats
• No murmur
• No thrill, heaving
• No edema
• Abdomen
• No abdominal distension
• Normoactive bowel sound
• Tenderness, rebound tenderness
• No palpable abdominal mass
Physical Examination
• HEENT • Back & Extremities
• Eyes • CVA tenderness (-)
• Normal sclera • Bone abnormality (-)
• Normal conjunctiva • No pitting edema
• No prominence of eyeball • No limitation of ROM
• Isocoric pupil, symmetric light reflex
• Ears
• Hearing difficulty (-)
• Discharge / Tinnitus (-/-)
• Nose
• Depression (-)
• Septal deviation (-)
• Neck
• Tenderness (-)
• Carotid bruit (-)
Initial Impression
#1 DM gastropathy
#2 Hyperglycemia (DKA)
#3 Viral/bacterial gastroenteritis
• Infectious colitis
Initial Diagnostic Plan
• Lab (CBC, chemistry, ABGA, urinalysis)
• X-ray (Chest, Abdomen erect & supine)
• EKG
X-ray (HD#1) – Chest
X-ray (HD#1) - Abdomen
Erect Supine
EKG (HD#1)
 CBC (HD#1)
검사명 결과 단위 참조치 참조치 검사명 결과 단 참조 참조
(L) (H) 위 치 (L) 치
WBC 11.5 10^3/uL 4 10.8 (H)
Hb 10.8 g/dl 12 16 WBC Differential Count
HCT 31.4 % 33 43 Band neutrophil %
MCV 85.8 fL 81 99 Segmented Neutrophil 82.5 % 40 74
MCH 29.4 pg 27 33 Lymphocyte 14.9 % 19 48
MCHC 34.3 g/dl 32 36 Monocyte 2.2 % 3.4 9
PCT 0.30 % 0.12 0.36 Eosinophil 0.0 % 0 7
MPV 8.5 fL 7.2 11.1 Basophil 0.4 % 0 1.5
PLT 352 10^3/uL 130 400 Atypical Lymphocyte %
Blast %
Immature cell %
Promyelocyte %
Myelocyte %
Metamyelocyte %
Chemistry (HD#1)
검사명 결과 단위 참조치 (L) 참조치 (H)
화학검사 ( 일반 ) [SST 8.5ml Serum]
Ca 9.64 mg/dL 8.4 10.0
Glucose 115 mg/dl 70 110
BUN 26.32 mg/dl 8 20
Creatinine 0.96 mg/dl 0.51 1.17
Protein, Total 6.69 g/dl 6.5 8.0
Albumin 3.47 g/dl 3.8 5.2
Alkaline Phosphatase 87 IU/L 40 120
AST(GOT) 23 IU/L 10 36
ALT(GPT) 12 IU/L 7 38
Bilirubin, Total 0.31 mg/dL 0.2 1.3
R-GT 13 IU/L 7 40
CPK 145 U/L 0 145
LDH 667 IU/L 200 450
Chemistry (HD#1)
검사명 결과 단위 참조치 (L) 참조치 (H)
Na 142 mmol/L 135 145
K 3.53 mmol/L 3.5 5.0
Cl 102.95 mmol/L 99 109
CO2 30.6 mmol/L 21 31
Osmolality(s) 294 mOsm/kg 270 310
Mg 2.48 mg/dL 1.9 2.4
Ketone body 445.3 umol/L 28 120
Anion Gap 8.5 mmol/L
CRP (quan) 0.1 mg/dl 0.5
eGFR 81.9 mL/min/1.73m2
Chemistry (HD#1)
검사명 결과 단위 참조치 (L) 참조치 (H)
화학검사 ( 일반 ) [EDTA]

HbA1c 7.2 % 4 6

검사명 결과 단위 참조치 (L) 참조치 (H)

화학검사 ( 일반 ) [Heparin]

NH3 24 umol/L 14.7 55.3

ABGA (HD#1) ER
검사명 결과 단위 참조치 (L) 참조치 (H)
Arterial Blood Gas
PH 7.324 7.28 7.46
PCO2 57.0 mmHg 32 46
PO2 37.6 mmHg 74 108
HCO3 29.9 mmol/L 24 26
Total CO2 31.6 mmol/L 21 29
Arterial BE 3.7 mmol/L 0 2
Standard BE 3.5 mmol/L 0 2
O2 saturation 65.6 % 92 96
Ionized calcium 4.59 mg/dL 4.5 5.3
Lactate 0.8 mmol/L 0.7 2.5
Urinalysis (HD#1)
검사명 결과 단위 참조치 (L) 참조치 (H)
Color Yellow
Turbidity Clear
S.G 1.018 1.000 1.050
pH 8.5 5.0 9.0
Protein ++++ -
Glucose + -
Ketone +- -
Blood - -
Urobilinogen - +-
Bilirubin - -
Nitrite - -
WBC - -
Micro RBC 6-10 /HPF 0 3
Micro WBC 0-2 /HPF 0 3
Micro Sediment No cast & crystal
Problem List
• Vomiting, heartburn, watery diarrhea
• Metabolic acidosis
• Mild leukocytosis
• HbA1c 7.2%
• Known Type 1 DM, HTN, retinopathy, nephropathy, neuropathy
Impression
#1 DM gastropathy
#2 Viral/bacterial gastroenteritis
• Infectious colitis
Further Evaluation
• BST f/u, urine microalbumin check, ABGA
• r/o viral/bacterial gastroenteritis – stool culture, PCR
• Imaging
• US abdomen
• CT abdomen & pelvis
ABGA (HD#1) END
검사명 결과 단위 참조치 (L) 참조치 (H)
Arterial Blood Gas
PH 7.394 7.28 7.46
PCO2 45.6 mmHg 32 46
PO2 94.1 mmHg 74 108
HCO3 28.1 mmol/L 24 26
Total CO2 29.5 mmol/L 21 29
Arterial BE 3.0 mmol/L 0 2
Standard BE 3.3 mmol/L 0 2
O2 saturation 97.2 % 92 96
24hr Random Urine (HD#2)
검사명 결과 단위 참조치 (L) 참조치 (H)
Protein quan, random urine 578.58 mg/dL
Glucose quan, random urine 2757 mg/dL
Creatinine, random urine 47.41 mg/dL
Microalbumin (urine) 4290 mg/L 0 30

ACR: 9048.7 mg/g = 1022.5 mg/mmol

PCR: 12203.8 mg/g = 1379 mg/mmol
Culture (HD#2)
검사명 결과
Gram stain
WBC Not found
EPI Not found
Gram (+) Not found
Gram(-) Not found
Culture & Sens (Ur0) Less than 1000 Cfu/mL

No evidence of infection
Reassment
• DM gastropathy aggravation
Treatment Plan
• Nutrition support, hydration, supportive care
• N/S 0.9% 50mL bag/IV/QD
• Sodium chloride 0.9% (Bag) 100mL bag/IV/QD

• Glycemic control – MSII (multiple subcutaneous insulin injection)

• Insulin Degludec ( 트레시바 )/SC/ 매일 아침 식후 22 단위
• Insulin Aspart ( 노보래피드 )/SC/ 매 식전 6-8 단위

• Symptomatic treatment
• Nausea
• Mirtazapine 7.5mg/PO/SP/PC 30 min
• Pantoprazole 40mg/IV/QD
• Ondansetron 8mg/IV/QD
• Dyspepsia
• Itopride HCL 50mg/PO/BF.L & S/AC 30min
• Sulcralfate 15mL 포 /PO/HS
• Prevent renal failure
• Valsartan 80mg/PO/BF/PC 30 min
Progress Note HD#4
S 화끈거리고 가슴에서 안내려가는 느낌이에요 . 토했어요 . 소화제좀 주세요 . 힘들어요 .
O Alert mental status
Vital sign stable
A DM gastropathy, aggravation, possible
Type 1 DM c gastropathy, neuropathy, reinopathy, nephropathy
r/p DM cystopathy (‘17)
r/o unspecified depressive disorder ('19.2)
Hx. Of DKA ('15)
P Fever & diarrhea 재차 발생시 mild leukocytosis 있어 culture & anti. 사용 필요할 수 있음
Nutrition support, hydration, supportive care, MSII
GAS consult
- 증세 악화 지속시 azithromycin PO, nasojejunal tube 삽입 고려
- 현재 환자의 증세가 저혈당과 함께 호전되었으므로 경과 관찰
- Itopride, domperidone 중단하고 필요하면 levosulpiride 로 변경
Progress Note HD#5
S 오늘 갑자기 많이 좋아졌어요 . 토하는 것도 좋아졌어요 . 저혈당 와서 그런 것 같아요
. 이번에 복귀하려고 아르바이트 시작했는데 그것 때문에 그런 것인지 특별히 잘못
먹은 것도 없었어요 . 보통 패턴이 4-5 일 아팠다가 저혈당 오면 좋아지더라고요 .
O Alert mental status
Vital sign stable
A DM gastropathy, aggravation, possible
Type 1 DM c gastropathy, neuropathy, reinopathy, nephropathy
r/p DM cystopathy (‘17)
r/o unspecified depressive disorder ('19.2)
Hx. Of DKA ('15)
P Nutrition support, hydration, supportive care, MSII
Ranitidine, sucralfate 추가 ( 속쓰립 , 변비 기운 )
Mirtazapine BID 로 횟수 증량
증상 호전되어 퇴원
Blood glucose level monitoring
400
344 345
350
311
300
250
250
214
195 203 197
192 182
200 180 178
mg/dL

163 154 163

143
150
113 113 113
100 84 80 90
67
54
50

0
0 0 0 0 0 0 0 2 0 6 0 0 3 0 0 0 0 0 0 9 0 0 0 0
:5 :0 :0 :0 :0 :0 :0 :3 :0 :5 :0 :0 :5 :0 :0 3:3 6:0 1:0 5:5 0:4 3:0 3:3 6:0 1:0
10 16 21 6 11 14 17 18 4 5 11 16 20 0 3 1 1 2 1

BST
TOPIC REVIEW
DM Gastropathy
Definition
• Delayed gastric emptying in the absence of obstruction, a
complication that affects patients with type 2 as well as type 1
diabetes mellitus
Symptoms
• Delayed gastric emptying (gastroparesis)
• Altered small- and large-bowel motility (constipation or diarrhea)
• May present w/ anorexia, nausea, vomiting, early satiety,
abdominal bloating
• Microvascular complications (retinopathy & neuropathy) usually
present
Diagnosis
• Nuclear medicine scintigraphy after ingestion of radiolabeled meal
– Dx delayed gastric emptying but not may not correlate with
symptoms
• Non-invasive “breath tests” after ingestion of radiolabeled meal
Treatment
Current treatments are inadequate and nonspecific
1. Goal – improved glycemic control
• Hasn’t shown clear benefit
2. 식단조절
• Smaller, more frequent, easy to digest meals (liquid) low in fat and fiber
• Minimizes symptoms

3. Medication that slows gastric emptying should be avoided

• Opioids
• GLP-1 receptor agonists

4. Metoclorpramide – for severe sx

5. Gastric electrical stimulatory devices – available but not yet approved
6. Diabetic diarrhea in the absence of bacterial overgrowth is treated
symptomatically
Reference
• Kasper, D. L., Fauci, A. S., Hauser, S. L., Longo, D. L., Jameson, J. L.,
& Loscalzo, J. (2018). Harrison’s principles of internal medicine (20th
edition.). New York: McGraw Hill Education.
• Koch, K. L., & Calles-Escandón, J. (2015). Diabetic gastroparesis.
Gastroenterology Clinics of North America, 44(1), 39-57.
doi:10.1016/j.gtc.2014.11.005