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Diabetes Mellitus

Diabetes Mellitus. Presented by Dr. Moosally Presented by Mick Svoboda. DM - metabolic disorder characterized by hyperglycemia secondary to either a deficiency of insulin production or resistance of target organs to insulin. 4 classes of DM. Type 1 Deficiency in insulin production

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Diabetes Mellitus

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  1. Diabetes Mellitus Presented by Dr. Moosally Presented by Mick Svoboda

  2. DM- metabolic disorder characterized by hyperglycemia secondary to either a deficiency of insulin production or resistance of target organs to insulin.

  3. 4 classes of DM • Type 1 • Deficiency in insulin production • Possible autoimmune etiology • Prone to DKA • Type 2 • Target organ resistance to insulin • Can progress to β cell failure • Susceptible to HHNK • Type 3 • Secondary causes- pancreatitis, hemachromatosis, drugs (glucocorticoids, dilantin) • Type 4 • Gestational DM

  4. Pathophysiology of DM • Tissues that readily take up glucose are most affected leading to intracellular accumulation. (retina, kidneys, nerves) • Accumulation of glycosylation end products lead to • Decreased nerve conduction- neuropathy • Accelerated atherogenesis- heart disease, CVA, nephropathy

  5. Clinical features • Type 1 frequently presents as DKA. • Type 2 can present as DKA or HHNK but is often an incidental finding on blood work or during findings suggestive of end organ damage. • Classic sx/sx- polyuria, polydypsia, polyphagia, poor wound healing, recurrent infections. • Key elements of history • New sxs, comorbid conditions, medication compliance • Key elements of PE • Thorough PE with focus on funduscopy, cardiac, extremity, skin, and neuro exam

  6. diagnosis • Sxs of DM w/ casual plasma glucose ≥ 200 mg/dL • FPG ≥ 126 mg/dL • 2-Hr PG ≥ 200 mg/dL

  7. Clinical features of acute hyperglycemia • Young adults- often c/o polyuria and/or polydipsia • Elderly- may present severely volume depleted w/ AMS, hypovolemic shock, and renal insufficiency • Assess lytes, anion gap, CBC, BUN/creatinine

  8. Treatment of acute hyperglycemiaDiscussed in more detail in DKA lecture • Includes volume replacement with NS boluses • Regular insulin • IV if pt volume depleted d/t erratic absorption. • SubQ in non-volume depleted pt. • Correction of electrolytes • Hypokalemia • Hypophosphatemia

  9. DM complications • Cardiovascular • Increased incidence of atherosclerosis of the coronary arteries • 2-4x greater to suffer ischemic heart ds or stroke than nonDM • Prone to atypical chest pain sxs • Weakness or SOB only • Retinopathy • Leading cause of blindness in pt 25-74 • Increased risk of cataracts and glaucoma • Watch for signs of acute glaucoma • Mid fixed dilated pupil, painful red eye, Increased IOP

  10. DM complications • Nephropathy • Leading cause of end-stage renal ds. • Hyperglycemia → hyperfiltration & glomerular hypertension → protein deposition → sclerosis of glomerulus. • Avoid use of NSAIDS • Neuropathy • Peripheral • Usu b/l with stocking/glove pattern • Progress form numbness → paresthesias/dysthesias → constant burning. • Autonomic • Clinical features- gastroparesis, GERD, neurogenic bladder, sexual dysftn, • Gastropaesis can be improved by reglan by ↓ gastric emptying time • GERD tx with H2 blockers, PPI • Neurogenic bladder may respond to bethanechol

  11. Infection in Diabetics • Pts w/ DM are more prone to infections vs. the general population • Factor such as neuropathy, impaired bladder emptying, poor circulation further hinder immune resp. • Fever in diabetics w/out a clear source should be admitted for further evaluation.

  12. Infectious complications • Rhinocerebral Mucormycosis • Invasive fungal infection • 70% of cases assoc. w/ DKA • Sxs • Unilateral HA, blood tinged nasal discharge, black eschar on the nasal mucosa d/t ischemia • TOC amphotercin B • Malignant Otitis Externa • Sxs of otitis externa c/ most pts having a mass of granular tissue. • Complication – osteomyelitis of the mastoid or temporal bone, meningitis • Include anti-pseudomonal coverage in abx regiment

  13. Infectious complications • Cholecystitis • Assoc. w/ higher M&M in diabetics • 25% more likely to develop emphysematous cholecystitis than non diabetic. • Consider this in DM pts w/ or w/out abd pain w/ unexplained fever.

  14. Foot and lower ext. ulcers • Complications account for 20% of diabetes related admissions and 60% LE amputations • Increased risk secondary to • Peripheral neuropathy • PVD • Impaired immunity • Infected wounds should be treated w/ broad spectrum abx w/ possible surg. consult • Uninfected ulcers that don’t involve deep structures can be treated w/ nonadherant dressings, non weight bearing, and appropriate follow-up.

  15. Skin and Soft tissue infections • Necrotizing Fascitis • Rapidly progressive infection of the skin and soft tissues. • Pain is often out of proportion compared to physical exam findings. • Initial appearance similar to cellulitis • Late findings include bullae and eschar w/ occasional crepitus in 50% of pts. • Radiographs may reveal gas w/in the tissue. • Tx consists of surgical consult and broad spectrum abx

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