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November 27, 2007

Aches and Pains, Complications

Question from Rockville, Maryland, USA:

My five-year-old son was diagnosed with type 1 diabetes almost four years ago. For the past six months, he has exhibited the symptoms of gastroparesis about four times (each a week long). It is possible he had a mild stomach "bug" when this happens but it is hard to tell what is making his stomach hurt. Recently, he had the same thing happen after being diagnosed with strep throat. Other times, he had no other symptoms but stomach discomfort. He experiences stomach discomfort and his food seems not to be absorbing as normal. He is usually able to eat an average amount of carbohydrates (for him) but his insulin needs become extremely unpredictable. Sometimes he does not need insulin for a meal for two to four hours after eating and sometimes doesn't need the usual amount for the carbohydrates he has eaten. He is on a pump, but it becomes almost impossible to predict how much insulin to give and when. Blood tests for celiac have been negative and his doctor does not know what causes these episodes. Can you suggest some reasons for this?

Answer:

It is extremely rare for very young children to have gastroparesis related to diabetes so I would go looking for other causes of such motility disturbances. There are several medications that may be tried to stimulate the gut to empty more reliably and working with an experienced pediatric gastroenterologist would be quite reasonable. Depending upon which tests for celiac disease have been used, this also should be rechecked and, specifically, one should use the transglutaminase antibody perhaps in addition to the anti-gliadin antibodies. Checking for immunoglobulin deficiency also helps since such tests could show false negative and only a biopsy would verify the diagnosis under such even more rare circumstances. Lastly, the new CGMS may be extremely valuable in such circumstances since it would identify trends of rising or falling glucose levels before they could otherwise be known and, therefore, you could respond by changing temporary basal rates via the pump more promptly.

SB