Transcript Risks for Complications in Diabetes

Dr : Reem Murad
The risk of chronic complications increases as a
function of the duration of hyperglycemia;
they usually become apparent in the second
decade of hyperglycemia.
Since type 2 DM often has a long asymptomatic
period of hyperglycemia, many individuals
with type 2 DM have complications at the time
of diagnosis.

Abnormal blood sugar

Abnormal cholesterol

Abnormal blood pressure

Sedentary lifestyle

Smoking

Blood glucose control A1C <7%

Treat cholesterol profiles to targets
Total cholesterol <200
 Triglycerides
<150
 HDL (“good”)
>40 men, >50 women
 LDL (“bad”)
<100, <70 high risk


Treat blood pressure to target <140/<80




(GI) disorders are common among all people,
including diabetics.
75% of patients visiting diabetes clinics will
report significant GI symptoms
The entire GI tract can be affected by diabetes
Common complaints may include dysphagia,
early satiety, reflux, constipation, abdominal
pain, nausea, vomiting, and diarrhea.


1.
2.
3.

Gastroparesis
intestinal enteropathy which can cause:
diarrhea
constipation
fecal incontinence
and nonalcoholic fatty liver disease.



1.
2.
3.
Gastroesophageal reflux disease (GERD )
more common in diabetics.
may be caused by
autonomic neuropathy with decreased lower
esophageal sphincter (LES) pressure
impaired clearance function of the tubular
esophagus
delayed gastric emptying.



is rarely clinically relevant
Dysphagia for liquids and/or solids is rarely
seen
dysphagia in diabetes mellitus is more
suspicious of peptic stricture, esophageal
cancer, rings (eg, Schatzki's ring) or webs than
dysmotility.



emptying of food from the stomach is delayed,
leading to retention of stomach contents
Diabetic autonomic neuropathy may include
vagal nerve dysfunction as well as sympathetic
nerve damage
can result in disordered motility of the small
bowel and the colon

food takes longer to pass through the stomach
than usual

Signs and symptoms:
bloating
2.
early satiety
3.
Distention
4.
abdominal pain
5.
nausea
6.
vomiting.
7.
gastroesophageal reflux
8. Heartburn
9.
Lack of appetite
10. Weight loss
1.


1.
2.
3.
4.
abnormalities at several levels in the process of gastric
emptying, including abnormal postprandial proximal
gastric accommodation and contraction, and difficulties
with antral motor function
these abnormalities are primarily due to
autonomic dysfunction
or abnormal intrinsic nervous system (eg, nitrergic
neurons, or interstitial cells of Cajal, the pacemaker system
of the gut)
An alternative theory implicates: a role for oxidative stress
May be a contribution from hyperglycemia itselfhyperglycemia typically has an acute, reversible effect
associated with poorly controlled diabetes (when blood
glucose is over 200 mg/dL)


Erratic blood glucose levels
Slower digestion can result in:
Bacterial overgrowth
Food can harden into solid masses
called bezoars that may cause
nausea, vomiting, and obstruction of
the stomach
Bezoars can be dangerous if they
block the passage of food into the
small intestine.



Symptoms
Upper GI endoscopy
The nuclear medicine gastric emptying test is
the best confirmatory test. A test solid-food
meal containing a technetium isotopic tracer is
ingested, and scintography is used to
quantitatively measure the rate of gastric
emptying. This test is highly sensitive and
specific


a barium X ray :swallow a liquid containing
the chemical barium, which shows up on X-ray
and highlights its passage through your
digestive system
a wireless capsule test – you swallow a small,
electronic device that sends information about
how fast it moves through your digestive tract
to a recording device







Meal and Food Changes
Consumption of frequent small
Avoidance of high-fat and high-fiber foods
liquid diet during an exacerbation of symptoms.
Smoking cessation
light postprandial exercise (such as walking)
Most importantly, careful attention to blood
glucose control.




Metclopropamide :a dopaminergic antagonist that
enhances gastric emptying and has primary
antiemetic properties
Cisapride (Propulsid) is a prokinetic agent effective at facilitating gastric emptying.
Domperidone (Motilium) is dopaminergic
antagonist similar to metclopropamide that
accelerates gastric emptying but does not cross the
blood-brain barrier and has very few side effects
Erythromycin has unique properties that stimulate
gastric motility and may be beneficial in selected
individuals.


Nonspecific antiemetic agents:
prochlorperazine (Compazine)
promethazine (Phenergan) provide
symptomatic relief of nausea and vomiting.
Recently use an implantable gastric
pacemaker..



surgery : insert a feeding tube. a jejunostomy tube,.
The feeding tube allows to put nutrients directly into
the small intestine, bypassing the stomach altogether.
A jejunostomy tube can be temporary and is used only
if necessary when gastroparesis is severe.
Botulinum toxin :More severe cases of gastroparesis
may be treated by injecting botulinum toxin into the
valve between the stomach and small intestine, to relax
it and keep it open for a longer period of time so food
can pass through.The injection is given through an
endoscope . found that it may not be very effective, so
it is not recommended by all doctors.





a common problem in patients with or without
diabetes
Helicobacter pylori,, is no more common in diabetics
treated in the same fashion regardless of whether
or not they have diabetes.
Treatment is geared toward suppression of gastric
acid secretion with antisecretory medications (i.e.,
H2 receptor antagonists or proton pump
inhibitors).
If H. pylori is present treat with a specific
antibiotic regimen along with anti-secretory
agents.



Common antibiotic regimens include a 2-week
course of amoxacillin)/clarithromycin metronidazole
/clarithromycin, metronidazole/tetracycline,
or metronidazole/amoxacillin.
In individuals with gastro-esophageal reflux,
eradication of H. pylori may result in worsening
symptoms because acid secretion increases
after this bacteria-related gastritis resolves.



yeast infections in the GI tract, especially with
bad glycemic control.
Yeast infection in the mouth is characterized by
a thick white coating of the tongue and throat
along with pain and burning.
If the infection extends further, candida
esophagitis results, which may cause intestinal
bleeding, heartburn, and difficulty swallowing.



Oral candida can readily be diagnosed by
physical examination
candida esophagitis will usually require
endoscopy for accurate diagnosis.
Treatment is highly effective and is focused on
the eradication of the yeast infection with
antifungal medications such as nystatin
(Mycostatin), ketocanazole (Nizoral), or
flucanazole (Diflucan).
longstanding diabetes, the enteric nerves
supplying the small intestine may be affected,
leading to
abnormal motility
abnormal secretion,
or abnormal absorption.






Diarrhea and rarely steatorrhea can occur in
diabetics, particularly those with advanced disease
The diarrhea is watery and painless, occurs at
night, and may be associated with fecal
incontinence.
diarrhea can be episodic or even alternating with
periods of constipation.
The prevalence of diabetic diarrhea has been
estimated to vary between 8 and 22 percent
Fecal incontinence due to anorectal impairment
has also been thought to be relatively common.



This may be due to autonomic neuropathy
leading to abnormal motility and secretion of
fluid in the colon.
Abnormal small bowel motility may be
associated with small bowel bacterial
overgrowth
intestinal problems ?. The most common is the
irritable bowel syndrome.




Fecal incontinence can result from anorectal
dysfunction
Medications ( metformin was an independent
risk factor for chronic diarrhea and fecal
incontinence)
exocrine pancreatic insufficiency is rare in
diabetics
association of celiac sprue with juvenile or
adult forms of insulin-dependent diabetes .



alterations in the endogenous bile salt pool and
increased fecal secretions of hydroxy fatty acids
may contribute to the pathogenesis of diabetic
diarrhea
Artificial sweeteners such as sorbitol or
polyols may have a role for diarrhea in
diabetics. The ingestion of as little as 10 g of
sorbitol can significantly alter bowel habits in
diabetics .
changes in blood glucose concentrations effect
on gastrointestinal sensory and motor function.


sprue may lead to diarrhea, weight loss, and
malabsorption of food.
This condition responds well to a gluten-free
diet, but patients may have difficulty adhering
to such a diet. Diagnosis can be made with
endoscopic biopsy of the small intestine or with
serological evaluation for anti-endomysial and
anti-gliadin antibodies.



should be directed at the identified cause of
diabetic enteropathy.
Patients with bacterial overgrowth should be
treated with antibiotics
For accelerated intestinal transit, a trial with
antidiarrheal agents such as lopiramide (2 to 4
mg four times daily), codeine (30 mg four times
daily), or diphenoxylate(5 mg four times daily)
has been proposed


Clonidine may have beneficial effects on both
accelerated intestinal transit and increased
small intestinal secretion.
The long-acting somatostatin analogue
octreotide has been tested against diabetic
diarrhea


Fiber supplementation with bran, Citrucel,
Metamucil, or high-fiber foods may also
thicken the consistency of the bowel movement
and decrease watery diarrhea.
antispasmodic medicines such as hyosymine
(Levsin), dicyclomine (Bentyl), and
chordiazepoxide (Librax)/clindinium (Clindex)
may decrease stool frequency.
treatment of fecal incontinence in diabetics
with chronic diarrhea involves two major
approaches:
- pharmacological intervention to reduce stool
volume and enhance stool consistency (
loperamide is recommendede)
- and techniques and toilet training
 celiac disease or exocrine pancreatic
insufficiency should be treated with a glutenfree diet or pancreatic enzyme
supplementation.





1.
2.
3.
4.
Constipation, may alternate with diarrhea, is one of the
most common complications of diabetes.
Neuronal dysfunction in the large bowel, along with
impairment of the gastrocolic reflex, results in
constipation.
It is important to rule out other causes of constipation
such as hypothyroidism or medications.
Treatment includes :
good hydration
regular physical activity
and increased fiber intake.
Sorbitol or lactulose can also be used to treat
constipation



enteric neuropathy may lead to a chronic
abdominal pain syndrome similar to the pain
of peripheral neuropathy in the feet.
This condition may be very difficult to treat sometimes respond to pain medications and
tricyclic antidepressant medications, such as
amitryptilline
narcotic addiction.




Pancreatic exocrine dysfunction occurs in up to
80% of individuals with type 1 diabetes
Rarely lead to any clinical problems with
digestion
The exocrine pancreas may also be affected in
some patients with type 2 diabetes but to a
lesser extent
who have secondary diabetes because of
severe pancreatitis or surgical removal of the
pancreas usually have more severe symptoms
of pancreatic exocrine insufficiency


Treatment with pancreatic enzyme
replacement therapy is usually effective.
A trial of oral enzyme replacement therapy can
be done safely for diagnostic and therapeutic
purposes.




GI problems in diabetes are common but not
commonly recognized in clinical practice
The duration of diabetes and the degree of glycemic
control are major determinants in the incidence and
severity of GI problems
The entire GI tract can be affected, including the
mouth, esophagus, stomach, small intestine, colon,
liver, and pancreas, leading to a variable symptom
complex.
The workup starts with a thorough patient history and
appropriate laboratory, radiographic, and GI testing. In
addition to pharmacological therapy, glycemic control
and dietary manipulation play an important role in
managing GI disorders in people with diabetes.