Diabetes

CASE REPORT SUBMITTED BY:MADEL DELA CRUZ SUBMITTED TO:MR.PEREA DIABETES MELLITUS - is a disorder in which blood sugar (glucose) levels are abnormally high because the body does not produce enough insulin to meet its needs. TYPES: ➢ Prediabetes is a condition in which blood sugar levels are too high to be considered normal but not high enough to be labeled diabetes. People have prediabetes if their fasting blood sugar level is between 101 mg/dL and 126 mg/dL or if their blood sugar level 2 hours after a glucose tolerance test is between 140 mg/dL and 200 mg/dL. Identifying people with prediabetes is important because the condition carries a higher risk for future diabetes as well as heart disease. Decreasing body weight by 5 to 10 % through diet and exercise can significantly reduce the risk of developing future diabetes. ➢ Type 1 diabetes (formerly called insulin-dependent diabetes or juvenile-onset diabetes), more than 90% of the insulin-producing cells of the pancreas are permanently destroyed. The pancreas, therefore, produces little or no insulin. Only about 10% of all people with diabetes have type 1 disease. Most people who have type 1 diabetes develop the disease before age 30. ➢ Type 2 diabetes was once rare in children and adolescents but has recently become more common. ➢ it usually begins in people older than 30 and becomes progressively more common with age. About 15% of people older than 70 have type 2 diabetes. ➢ People of certain racial and ethnic backgrounds are at increased risk of developing type 2 diabetes: blacks, Native Americans, and Hispanics who live in the United States have a twofold to threefold increased risk. ➢ Type 2 diabetes also tends to run in families. ➢ Obesity is the chief risk factor for developing type 2 diabetes, and 80 to 90% of people with this disorder are overweight or obese. Because obesity causes insulin resistance, obese people need very large amounts of insulin to maintain normal blood sugar levels. ➢ Certain disorders and drugs can affect the way the body uses insulin and can lead to type 2 diabetes. High levels of corticosteroids (from Cushing's disease or from taking corticosteroid drugs) and pregnancy (gestational diabetes are the most common causes of altered insulin use. ➢ Diabetes also may occur in people with excess production of growth hormone (acromegaly) and in people with certain hormone-secreting tumors. ➢ Severe or recurring pancreatitis and other disorders that directly damage the pancreas can lead to diabetes CLINICAL MANIFESTATIONS: Clinical manifestations depend on the patient’s level of hyperglycemia. Classic manifestations of all types of diabetes include the 3p’s: ➢ Polyuria - When the blood sugar level rises above 160 to 180 mg/dL, sugar spills into the urine. When the level of sugar in the urine rises even higher, the kidneys excrete additional water to dilute the large amount of sugar. Because the kidneys produce excessive urine, people with diabetes urinate large volumes frequently. ➢ Polydypsia - The excessive urination creates abnormal thirst ➢ Polyphagia - Because excessive calories are lost in the urine, people lose weight. To compensate, people often feel excessively hungry. Other symptoms include: ➢ Fatigue and weakness ➢ Sudden vision changes ➢ Tingling or numbness in hands ➢ Dry skin ➢ Skin lesions or wounds that are slow to heal ➢ Recurrent infection ➢ Type 1: In people with type 1 diabetes, the symptoms often begin abruptly and dramatically. A condition called diabetic ketoacidosis may quickly develop. Without insulin, most cells cannot use the sugar that is in the blood. Cells still need energy to survive, and they switch to a back-up mechanism to obtain energy. Fat cells begin to break down, producing compounds called ketones. Ketones provide some energy to cells but also make the blood too acidic (ketoacidosis). The initial symptoms of diabetic ketoacidosis include excessive thirst and urination, weight loss, nausea, vomiting, fatigue, and—particularly in children—abdominal pain. Breathing tends to become deep and rapid as the body attempts to correct the blood's acidity. The breath smells like nail polish remover, the smell of the ketones escaping into the breath. Without treatment, diabetic ketoacidosis can progress to coma and death, sometimes within a few hours ➢ Type 2: People with type 2 diabetes may not have any symptoms for years or decades before they are diagnosed. Symptoms may be subtle. Increased urination and thirst are mild at first and gradually worsen over weeks or months. Eventually, people feel extremely fatigued, are likely to develop blurred vision, and may become dehydrated. ➢ Sometimes during the early stages of diabetes, the blood sugar level is abnormally low, a condition called hypoglycemia ➢ Because people with type 2 diabetes produce some insulin, ketoacidosis does not usually develop. However, the blood sugar levels can become extremely high (often exceeding 1,000 mg/dL). Such high levels often happen as the result of some superimposed stress, such as an infection or drug use. When the blood sugar levels get very high, people may develop severe dehydration, which may lead to mental confusion, drowsiness, and seizures, a condition called nonketotic hyperglycemic-hyperosmolar coma. COMPLICATIONS: Acute Complications: ➢ Hypoglycemia ➢ Diabetic ketoacidosis ➢ Hyperglycemic hyperosmolar nonketotic syndrome(HHNS) |Long-Term Complications of Diabetes | | | |Tissue or Organ Affected | |What Happens | |Complications | | | |Blood vessels | |Fatty material (atherosclerotic plaque) builds up and blocks large or medium-sized arteries in the heart, brain, legs, and | |penis. | |The walls of small blood vessels are damaged so that the vessels do not transfer oxygen to tissues normally, and the vessels may| |leak. | |Poor circulation causes wounds to heal poorly and can lead to heart disorders, strokes, gangrene of the feet and hands, erectile| |dysfunction (impotence), and infections. | | | |Eyes | |The small blood vessels of the retina are damaged. | |Decreased vision and, ultimately, blindness occur. | | | |Kidney | |Blood vessels in the kidney thicken. | |Protein leaks into urine. | |Blood is not filtered normally. | |The kidneys malfunction, and ultimately, kidney failure occurs. | | | |Nerves | |Autonomic nervous system | |The nerves that control blood pressure and digestive processes are damaged. | |Swings in blood pressure occur. | |Swallowing becomes difficult. | |Digestive function is altered, and sometimes bouts of diarrhea occur. | |Erectile dysfunction develops. | | | | | |Skin | |Blood flow to the skin is reduced, and sensation is decreased, resulting in repeated injury. | |Sores and deep infections (diabetic ulcers) develop. | |Healing is poor. | | | | | | | | | | | |Blood | |White blood cell function is impaired. | |People become more susceptible to infections, especially of the urinary tract and skin. | | | |Connective tissue | |Glucose is not metabolized normally, causing tissues to thicken or contract. | |Carpal tunnel syndrome and Dupuytren's contracture develop. | | | |The Foot in Diabetes | |Diabetes causes many changes in the body. The following | |changes in the feet are common and difficult to treat. | |Damage to the nerves (neuropathy) affects sensation to | |the feet, so that pain is not felt. Irritation and other | |forms of injury may go unnoticed. An injury may wear | |through the skin before any pain is felt. | |Changes in sensation alter the way people with diabetes | |carry weight on their feet, concentrating weight in | |certain areas so that calluses form. Calluses (and dry | |skin) increase the risk of skin breakdown. | |Diabetes can cause poor circulation in the feet, making | |ulcers more likely to form when the skin is damaged and | |making the ulcers slower to heal. | |Because diabetes can affect the body's ability to fight | |infections, a foot ulcer, once it forms, easily becomes | |infected. Because of neuropathy, people may not feel | |discomfort from the infection until it becomes serious | |and difficult to treat, leading to gangrene. People with | |diabetes are more than 30 times more likely to require | |amputation of a foot or leg than are people without | |diabetes. | TYPES OF FOOT GANGRENE  |[pic] | Gangrene usually follows a disorder that cuts off the blood supply to a diseased or injured area of the body resulting in an inability of the tissue to repair, thus stay alive. DRY GANGRENE - also called secondary gangrene or mummification - the most common category of gangrene - is a complication resulting from degenerative changes associated with chronic diseases, such as diabetes mellitus and/or atherosclerosis. It is caused by a gradual reduction in the blood supply to the tissues, and is almost exclusively limited to the extremities - especially feet and toes. In other words, when tissues are deprived of the nutrients and oxygen carried by blood, they begin to die. In early stages, dry gangrene causes some dull, aching pain - the affected area is extremely painful to palpate (feel, touch). Then, it becomes cold, dry and wrinkled. In later stages of gangrene, the skin gradually changes in color to dark brown, then a dark purplish-blue, then completely black (resulting from formation of iron sulfide from decomposed hemoglobin). With the withering, drying out of tissue, little tissue liquefaction and, generally, with no bacterial decomposition (hence the term "dry gangrene" or "mummification"), this condition may continue unnoticed for weeks or months, especialy in elderly persons. Finally, the affected gangrenous tissues become visibly separated from the surrounding healthy tissues. Utimately, they become dessicated (dried up) and mummified. Dry gangrene of this magnitude is rare except when patients refuse amputation. Once again, areas of dry gangrene are initially characterized by a red line on the skin that marks the border of the affected tissues. As the blood supply deteriorates to a stage where insufficient blood is available to keep the tissues alive so they begin to die, dry gangrene may cause some pain in the early stages or may go unnoticed, especially in the elderly or in those individuals with diminished sensation to the affected area. Initially, the area becomes cold, numb, and pale before later changing in color to brown, then black. If the dead tissues in the extremities remain dry (mummified) and free from infection (asceptic), then they gradually separate from the healthy, non-gangrenous tissues become withered - dry and shrivelled, and sometimes autoamputate and fall off without surgery (this applies mostly to the gangrenous toes that are stable and have no signs of infection). |[pic] | WET MOIST FOOT GANGRENE - is the more serious condition, as it usually indicates a bacterial infection that may spread and be fatal. It presents like dry gangrene, but is softer to touch with copious tissue liquefaction (hence the term "wet gangrene") and an offensive odor, smell. The foot or toe may be swollen, red and warm. Most commonly wet gangrene is caused by an acute occlusion (complete obstruction), such as: ➢ Peripheral vascular disease (PVD), ➢ Tourniquet (a bandage twisted tight to check bleeding or blood flow), ➢ Restrictive bandage or Trauma (injury, wound). Gangrene is often treated by an operation to remove the dead tissue. If it's an area of tissue that can be removed, the operation is called debridement - the surgical removal of lacerated, devitalized, or contaminated tissue. If it's a leg, foot, finger, or toe that have to be removed, the operation is called an amputation - the surgical removal of an affected part of the body. Transmetatarsal amputation - an amputation of the distal third of the foot - is most commonly performed for gangrene or non-healing ulcer of the toes. It is indicated, if: amputation of more than two toes is required and gangrene extends proximal to the metatarsal-phalangeal joint. Gangrenous lesions may be due to emboli, atherosclerosis, or diabetic neuropathy. Below on the left is a photograph of a diabetic foot with a transmetatarsal amputation taken three weeks after surgical intervention (the wound still visible). |[pic] | Below on the right is a photograph of a diabetic foot with a previous healed transmetatarsal amputation that demonstrates an ulcer in the region of the ankle |[pic] | Please note that transmetatarsal amputation is a viable alternative to below-knee amputation in patients with deep forefoot infection, necrosis, or unreconstructible trauma.) DIAGNOSIS: ➢ FASTING PLASMA GLUCOSE – An abnormally high blod glucose level is the basic criteria for the diagnosis of diabetes.FPG levels of 126 mg/dl