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usually chronic with exacerbations and can cause significant detriment to quality of life and productivity . 3 The impact of gastroparesis extends beyond the individual .
A 2017 US national database analysis identified a significant increase in hospital inpatient admissions and associated costs for gastroparesis between 1997 and 2013 . 4
Diabetes is the most common cause , while some cases may be post-surgical or idiopathic . 5 The condition has been documented in up to 50 % of patients with moderately controlled type 1 and type 2 diabetes . 6 Understanding of the pathogenesis of diabetic gastroparesis has evolved , and autonomic neuropathy is no longer considered the sole cause of gastrointestinal dysmotility . 7 The role of enteric neurons , interstitial cells in the gastrointestinal tract , smooth muscle and enteric microbiota has been highlighted . 7
Gastroparesis often leads to reduced oral intake and possible weight loss . 8 Management aims to mitigate gastrointestinal symptoms and ensure adequate nutritional intake . Antiemetics are a predominant first-line therapy . 6 However , nutritional intervention and dietary modifications can assist in both maintaining nutrition status and possible symptom relief . The release of endogenous cholecystokinin following dietary intake of high-fat foods delays gastric emptying . 9 Dietary fibre contributes to gastric food retention , so limiting fibre intake may improve gastroparesis symptoms . 10 Gastric emptying of liquids is often not impacted in individuals with gastroparesis . A randomised controlled trial that prescribed a small particle – size diet also demonstrated reduced gastrointestinal symptoms for patients with insulin-dependent diabetes and gastroparesis . 8 , 11 Therefore , specific dietary modifications may include avoiding high-fat or high-fibre foods and consuming a greater proportion of liquids over solid foods . 8
Although implementation of dietary
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modifications may have the potential to alleviate gastroparesis symptoms , they are somewhat contradictory to mainstay nutritional recommendations for diabetes . 12 , 13 Following a low GI diet to manage postprandial blood glucose levels is recommended , and incorporating high-fibre lower GI foods aids glycaemic control . 14 , 15 The complexity of managing conflicting recommendations highlights some of the challenges associated with the management of gastroparesis associated with diabetes . The relationship between glycaemic control and gastric emptying has been described as bidirectional — whereby hyperglycaemia contributes to delayed gastric motility and improved glycaemia may improve delayed gastric emptying . A multimodal , multidisciplinary approach is central to optimising gastrointestinal symptoms , ensuring nutritional adequacy and assisting in improving glycaemia for individuals with gastroparesis .
Outcome
Six weeks post-discharge , Jamilla is reviewed in the dietitian outpatient clinic . She reports her gastrointestinal symptoms are well controlled . Erythromycin has been ceased after four weeks with no significant changes in symptoms . She is tolerating three regular meals a day and has maintained her weight . However , Jamilla reports she has been experiencing hyperglycaemia postmeals followed by hypoglycaemic episodes . Upon review , it is noted that Jamilla has continued to have her prandial insulin around 15 minutes after eating . She notes that her blood glucose levels rise and then she corrects these with additional insulin within two hours , causing her blood glucose levels to drop below 4mmol / L . With the improvement of Jamilla ’ s gastrointestinal symptoms and reduced gastric emptying time , it is recommended she return to having her bolus insulin 15 minutes before meals . References on request from kate . kelso @ adg . com . au
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Diabetes is the most common cause of gastroparesis , while some cases may be post-surgical or idiopathic .
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The answer is c . The unnoticed attachment and subsequent persistent itching align with the characteristics of leech bites . In this case , the presence of two bites may be attributed to the characteristics of leech blood-feeding behaviour . Leeches — known as sangsue in French , meaning ‘ blood suckers ’ — typically have three jaws and create multiple incisions as they move during feeding . Therefore , bites from a single leech may appear as distinct lesions because of leech movement or reattachment .
Leech bites are painless as leeches secrete anaesthetic substances during attachment . In this instance , the patient ’ s initial lack of awareness and subsequent discovery of blood on her shoe align with the typical features of leech bites . The patient later recalled someone in a restaurant , where she had stopped for lunch , commenting that they had found an engorged leech on the floor , which may have dropped off after feeding . The persistent itching experienced by the patient is consistent with the inflammatory response triggered by substances present in leech saliva .
Leech bites have been reported to transmit bloodborne viruses — including hepatitis B and HIV — in endemic areas of high prevalence , such as Africa . If bites occur in a region of high prevalence , serological testing may be indicated . Otherwise , management is symptomatic only . A topical steroid may aid with itch , and a topical antibiotic can be applied if there are features of infection . The reaction may take a week to subside .
Cutaneous leishmaniasis often presents as crusted or ulcerated papules from the bite of a sandfly . The lesions usually appear weeks or months after the bite . Typically , cutaneous leishmaniasis is found in more tropical and subtropical regions . In Australia , leishmaniasis has only been reported in patients who have acquired it overseas .
Spider bites can result in localised skin reactions , often associated with pain , redness and swelling . The absence of significant pain and the persistent itching make a spider bite less likely .
Insect bites can cause localised erythema , itching and discomfort . However , the patient ’ s delayed awareness of the lesions is less typical . Persistent pruritus also deviates from the usual symptoms associated with insect bites .
References on request from kate . kelso @ adg . com . au
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