A woman has had type 1 diabetes mellitus for 16 years and ha

A 29-year-old woman has had type 1 diabetes mellitus for 16 years and has been your patient for ten years. During the past three years blood pressure has increased from 110/70 to 135/86 mmHg. Her HbA1C has ranged from 8% to 9% (3.8-6.4).

Today her blood pressure is 130/84 mmHg. She also has noticed that her home blood glucose levels fluctuate more so than normal over the last three months. She also informs you that she is aware of nausea after eating and has required less food than usual to satisfy her appetite.

Investigations show:
Urea 12.5 mmol/L (2.5-7.5)
Creatinine 120 µmol/L (60-110)
Sodium 136 mmol/L (137-144)
Potassium 4.2 mmol/L (3.5-4.9)
Bicarbonate 24 mmol/L (20-28)
HbA1C 6% (3.8-6.4)
Urinalysis: Protein+
Which of the following is the most likely cause of her symptoms?
(Please select 1 option)

Adrenal insufficiency

Incipient renal failure

Impaired epinephrine release

Delayed gastric emptying

Inaccurate insulin administration

Answer: Delayed gastric emptying

She has a long history of diabetes and reports nausea after eating with the impression of fullness and hence reduced appetite. This suggests reduced gastric emptying and would be compatible with an autonomic neuropathy. Other features that would be worth asking about include features of postural hypotension, gustatory sweating, diarrhoea or change in bowel habit. The diagnosis can be confirmed with barium swallow and meal.