The Gastrointestinal Manifestations of Type One Diabetes Mellitus in Children

Abstract

Introduction

Type one diabetes mellitus (T1DM) is one of the most common, serious chronic diseases of childhood. Hyperglycaemia causes well known micro- and macro- vascular complications. Less well explored are the ways the gastrointestinal (GI) system is affected. This research aimed to examine in depth three aspects of the gastrointestinal manifestations of T1DM. Coeliac Disease Coeliac Disease (CD) occurs more frequently in children with T1DM, the two diseases share genetic and environmental risk factors. To establish how clinicians in New Zealand screen for and manage CD in T1DM, a benchmark survey was performed. All paediatricians caring for children with T1DM in NZ were sent an online questionnaire with multi-choice and open questions regarding their individual practice. Ninety-two percent of the clinicians replied. Most screen for coeliac disease in T1DM but approximately a third do not. Those that do not screen use poor control, poor growth and GI symptoms as a trigger for testing. All were sensitive to the burden of the double diagnosis. Gastric emptying Gastric emptying has been demonstrated to be delayed in adults with T1DM, which has potential adverse effects on blood sugar control and symptomatology. Evidence regarding the rate of gastric emptying in children with T1DM is conflicting and inconclusive. This pilot study aimed to investigate gastric emptying in children with T1DM and in health. Gastric emptying was measured using Carbon 13 (C13) breath testing, a non-invasive, very low risk procedure. Nineteen cases and 15 age and sex matched controls underwent testing. The mean gastric emptying coefficient [mean (95% CI)] in cases was higher than in controls, indicating a shorter gastric emptying time (3.19 (2.97 – 3.41) vs 2.90 (2.74 - 3.10), p = 0.03). Mean GET1/2 [mean (95% CI)] was not different between the two groups (cases 99 (68 - 128) mins vs 103 (88-118) mins, p = 0.8). Secondary analysis suggested that there was a relationship between the duration of T1DM and the speed of gastric emptying but numbers were small and the result did not meet statistical significance. Gastrointestinal symptoms: Anecdotally children with T1DM are said to complain of more GI symptoms than their healthy peers. We aimed to prospectively establish the frequency and intensity of GI symptoms in a clinic population of New Zealand children with T1DM compared to an aged-matched group of healthy children. Caregivers were given a 10 item questionnaire about their child’s experience of GI symptoms in the previous month. Responses were marked on a Likert scale, from 0 (not at all) to 4 (a whole lot). Participant’s scores for each question were also summed together to give an overall score as a marker of the overall intensity of symptoms. Two hundred and forty four children completed the questionnaire. Cases and controls had similar rates of any GI symptoms (80% of controls v 85% cases, OR 1.5 (95% CI: 0.7-3.1)). Children with T1DM had higher mean scores for abdominal pain (1.3 v 1.0, p = 0.02) and reflux (0.4 v 0.20, p = 0.02). The overall mean score was also higher in cases (4.9 v 3.4, p = 0.02) indicating the intensity of their complaints was higher than healthy controls. Conclusion: This thesis shows the importance of the gastrointestinal manifestations of T1DM in children. Further research to expand upon our knowledge of these manifestations will allow for improved management of T1DM in children.