Diagnostic Approach

  • Ayah Oglat
  • Eamonn M. M. QuigleyEmail author
Part of the Clinical Gastroenterology book series (CG)


For the most part, the evaluation of upper gastrointestinal symptoms in diabetics should be similar to that in nondiabetics. In the assessment of GERD, however, it seems prudent to pay attention to esophageal motor function given the high prevalence of esophageal dysmotility among diabetics. The assessment of symptoms suggestive of gastroparesis can be challenging but should, as in all instances of gastrointestinal symptomatology, begin with an evaluation of glycemic control and a search of alternative explanations for symptoms in the stomach as well as elsewhere throughout the gut. Though it correlates poorly with symptomatology, an accurate assessment of gastric emptying rate is important, if only to rule out those instances of accelerated emptying.


Diabetes mellitus Gastroesophageal reflux Dysphagia Esophageal dysmotility Esophageal manometry Nausea and vomiting Dyspepsia Gastroparesis Gastric emptying 



Computed tomography


Distal contractile integral




Endoscopic functional luminal imaging probe


Gastroesophageal reflux disease


High-resolution manometry


Integrated relaxation pressure


Magnetic resonance


Nonsteroidal anti-inflammatory drug


  1. 1.
    Quigley EM, Hasler WL, Parkman HP. AGA technical review on nausea and vomiting. Gastroenterology. 2001;120:263–86.CrossRefPubMedGoogle Scholar
  2. 2.
    Chaikomin R, Rayner CK, Jones KL, Horowitz M. Upper gastrointestinal function and glycemic control in diabetes mellitus. World J Gastroenterol. 2006;12:5611–21.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Hasler WL, Parkman HP, Wilson LA, Pasricha PJ, Koch KL, Abell TL, et al. Psychological dysfunction is associated with symptom severity but not disease etiology or degree of gastric retention in patients with gastroparesis. Am J Gastroenterol. 2010;105:2357–67.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Armstrong D, Bennett JR, Blum AL, Dent J, De Dombal FT, Galmiche JP, et al. The endoscopic assessment of esophagitis: a progress report on observer agreement. Gastroenterology. 1996;111:85–92.CrossRefPubMedGoogle Scholar
  5. 5.
    Lundell LR, Dent J, Bennett JR, Blum AL, Armstrong D, Galmiche JP, et al. Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut. 1999;45:172–80.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Lucendo AJ. Esophageal manifestations of celiac disease. Dis Esophagus. 2011;24:470–5.CrossRefPubMedGoogle Scholar
  7. 7.
    Lucendo AJ, Molina-Infante J, Arias Á, von Arnim U, Bredenoord AJ, Bussmann C, et al. Guidelines on eosinophilic esophagitis: evidence-based statements and recommendations for diagnosis and management in children and adults. United European Gastroenterol J. 2017;5:335–58.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Sharma P, Dent J, Armstrong D, Bergman JJ, Gossner L, Hoshihara Y, et al. The development and validation of an endoscopic grading system for Barrett’s esophagus: the Prague C & M criteria. Gastroenterology. 2006;131:1392–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Herregods TV, Roman S, Kahrilas PJ, Smout AJ, Bredenoord AJ. Normative values in esophageal high-resolution manometry. Neurogastroenterol Motil. 2015;27:175–87.CrossRefPubMedGoogle Scholar
  10. 10.
    Kahrilas PJ, Bredenoord AJ, Fox M, Gyawali CP, Roman S, Smout AJ, International High Resolution Manometry Working Group, et al. The Chicago Classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil. 2015;27:160–74.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Schlottmann F, Herbella FA, Patti MG. Understanding the Chicago Classification: from tracings to patients. J Neurogastroenterol Motil. 2017;23:487–94.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    George NS, Rangan V, Geng Z, Khan F, Kichler A, Gabbard S, et al. Distribution of esophageal motor disorders in diabetic patients with dysphagia. J Clin Gastroenterol. 2017;51:890–5.CrossRefPubMedGoogle Scholar
  13. 13.
    Pandolfino JE, Kwiatek MA. Use and utility of the Bravo pH capsule. J Clin Gastroenterol. 2008;42:571–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Wilson JA, Vela MF. New esophageal function testing (impedance, Bravo pH monitoring, and high-resolution manometry): clinical relevance. Curr Gastroenterol Rep. 2008;10:222–30.CrossRefPubMedGoogle Scholar
  15. 15.
    Gyawali CP, Roman S, Bredenoord AJ, Fox M, Keller J, Pandolfino JE, et al. Classification of esophageal motor findings in gastro-esophageal reflux disease: conclusions from an international consensus group. Neurogastroenterol Motil. 2017;29. [epub ahead of print].
  16. 16.
    Hirano I, Pandolfino JE, Boeckxstaens GE. Functional lumen imaging probe for the management of esophageal disorders: expert review from the Clinical Practice Updates Committee of the AGA Institute. Clin Gastroenterol Hepatol. 2017;15:325–34.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Pasricha PJ, Parkman HP. Gastroparesis: definitions and diagnosis. Gastroenterol Clin N Am. 2015;44:1–7.CrossRefGoogle Scholar
  18. 18.
    Hoogerwerf WA, Pasricha PJ, Kalloo AN, Schuster MM. Pain: the overlooked symptom in gastroparesis. Am J Gastroenterol. 1999;94:1029–33.CrossRefPubMedGoogle Scholar
  19. 19.
    Cherian D, Sachdeva P, Fisher RS, Parkman HP. Abdominal pain is a frequent symptom of gastroparesis. Clin Gastroenterol Hepatol. 2010;8:676–81.CrossRefPubMedGoogle Scholar
  20. 20.
    Hasler WL, Wilson LA, Parkman HP, Koch KL, Abell TL, Nguyen L, et al. Factors related to abdominal pain in gastroparesis: contrast to patients with predominant nausea and vomiting. Neurogastroenterol Motil. 2013;25:427–38.CrossRefPubMedGoogle Scholar
  21. 21.
    Quigley EM. Symptoms and gastric function in dyspepsia—goodbye to gastroparesis? Neurogastroenterol Motil. 1996;8:273–5.CrossRefPubMedGoogle Scholar
  22. 22.
    Stanghellini V, Tosetti C, Paternico A, Barbara G, Morselli-Labate AM, et al. Risk indicators of delayed gastric emptying of solids in patients with functional dyspepsia. Gastroenterology. 1996;110:1036–42.CrossRefPubMedGoogle Scholar
  23. 23.
    Jones KL, Russo A, Stevens JE, et al. Predictors of delayed gastric emptying in diabetes. Diabetes Care. 2001;24:1264–9.CrossRefPubMedGoogle Scholar
  24. 24.
    Samsom M, Vermeijden JR, Smout AJ, et al. Prevalence of delayed gastric emptying in diabetic patients and relationship to dyspeptic symptoms: a prospective study in unselected diabetic patients. Diabetes Care. 2003;26:3116–22.CrossRefPubMedGoogle Scholar
  25. 25.
    Quigley EM. Review article: gastric emptying in functional gastrointestinal disorders. Aliment Pharmacol Ther. 2004;20(Suppl 7):56–60.CrossRefPubMedGoogle Scholar
  26. 26.
    Frank JW, Saslow SB, Camilleri M, Thomforde GM, Dinneen S, Rizza RA. Mechanism of accelerated gastric emptying of liquids and hyperglycemia in patients with type II diabetes mellitus. Gastroenterology. 1995;109:755–65.CrossRefPubMedGoogle Scholar
  27. 27.
    Bharucha AE, Camilleri M, Forstrom LA, Zinsmeister AR. Relationship between clinical features and gastric emptying disturbances in diabetes mellitus. Clin Endocrinol. 2009;70:415–20.CrossRefGoogle Scholar
  28. 28.
    Quigley EM. The clinical pharmacology of motility disorders: the perils (and pearls) of prokinesia. Gastroenterology. 1994;106:1112–4.CrossRefPubMedGoogle Scholar
  29. 29.
    Camilleri M, Malagelada JR, Abell TL, Brown ML, Hench V, Zinsmeister AR. Effect of six weeks of treatment with cisapride in gastroparesis and intestinal pseudoobstruction. Gastroenterology. 1989;96:704–12.PubMedGoogle Scholar
  30. 30.
    McCallum RW, Chen JD, Lin Z, Schirmer BD, Williams RD, Ross RA. Gastric pacing improves emptying and symptoms in patients with gastroparesis. Gastroenterology. 1998;114:456–61.CrossRefPubMedGoogle Scholar
  31. 31.
    Janssen P, Harris MS, Jones M, et al. The relation between symptom improvement and gastric emptying in the treatment of diabetic and idiopathic gastroparesis. Am J Gastroenterol. 2013;108:1382–91.CrossRefPubMedGoogle Scholar
  32. 32.
    Camilleri M, Hasler WL, Parkman HP, Quigley EM, Soffer E. Measurement of gastrointestinal motility in the GI laboratory. Gastroenterology. 1998;115:747–62.CrossRefPubMedGoogle Scholar
  33. 33.
    den Hartog G, Mulder CJ, Thies JE, Wiersma TG. The constipated stomach. An underdiagnosed problem in patients with abdominal pain? Scand J Gastroenterol Suppl. 1998;225:41–6.Google Scholar
  34. 34.
    Spiller RC. Upper gut dysmotility in slow-transit constipation: is it evidence for a pan-enteric neurological deficit in severe slow transit constipation? Eur J Gastroenterol Hepatol. 1999;11:693–6.CrossRefPubMedGoogle Scholar
  35. 35.
    Ropert A, Cherbut C, Rozé C, Le Quellec A, Holst JJ, Fu-Cheng X, et al. Colonic fermentation and proximal gastric tone in humans. Gastroenterology. 1996;111:289–96.CrossRefPubMedGoogle Scholar
  36. 36.
    Piche T, Zerbib F, Varannes SB, Cherbut C, Anini Y, Roze C, et al. Modulation by colonic fermentation of LES function in humans. Am J Physiol Gastrointest Liver Physiol. 2000;278:G578–84.CrossRefPubMedGoogle Scholar
  37. 37.
    Piche T, des Varannes SB, Sacher-Huvelin S, Holst JJ, Cuber JC, Galmiche JP. Colonic fermentation influences lower esophageal sphincter function in gastroesophageal reflux disease. Gastroenterology. 2003;124:894–902.CrossRefGoogle Scholar
  38. 38.
    Abell TL, Camilleri M, Donohoe K, et al. Consensus recommendations for gastric emptying scintigraphy: a joint report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine. Am J Gastroenterol. 2008;103:753–63.CrossRefPubMedGoogle Scholar
  39. 39.
    Tougas G, Eaker EY, Abell TL, et al. Assessment of gastric emptying using a low fat meal: establishment of international control values. Am J Gastroenterol. 2000;95:1456–62.CrossRefPubMedGoogle Scholar
  40. 40.
    Ghoos YF, Maes BD, Geypens BJ, Mys G, Hiele MI, Rutgeerts PJ, Vantrappen G. Measurement of gastric emptying rate of solids by means of a carbon-labeled octanoic acid breath test. Am J Gastroenterol. 2003;98:2122–9.CrossRefGoogle Scholar
  41. 41.
    Choi MG, Camilleri M, Burton DD, Zinsmeister AR, Forstrom LA, Nair KS. Reproducibility and simplification of 13C-octanoic acid breath test for gastric emptying of solids. Am J Gastroenterol. 1998;93:92–8.CrossRefPubMedGoogle Scholar
  42. 42.
    Szarka LA, Camilleri M, Vella A, Burton D, Baxter K, Simonson J, et al. A stable isotope breath test with a standard meal for abnormal gastric emptying of solids in the clinic and in research. Clin Gastroenterol Hepatol. 2008;6:635–43.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Kuo B, McCallum RW, Koch KL, Sitrin MD, Wo JM, Chey WD, et al. Comparison of gastric emptying of a nondigestible capsule to a radio-labelled meal in healthy and gastroparetic subjects. Aliment Pharmacol Ther. 2008;27:186–96.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Lynda K. and David M. Underwood Center for Digestive Disorders, Division of Gastroenterology and HepatologyHouston Methodist HospitalHoustonUSA

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