Diabetic Ketoacidosis

DIABETES MELLITUS

-Is a group of metabolic diseases in which there are high blood sugar levels over a prolonged period,Diabetes is due to either the pancreas not producing enough insulin or the cells of the body not responding properly to the insulin produced.

-Types of diabetes mellitus :

*Type 1 DM (IDDM-insulin dependent)

-usually juvenile onset but may accur at any age

-causes of IDDM :

.insulin deficiency due to selective destruction of insulin secreting pancreatic beta cells

-Pt always need insulin and prone to ketoacidosis and wight loss

-it is associated with other autoimmune diseases (HLA-B8/HLA-B15/HLA-DR3/HLA-DR4)

*Type 2 DM (NIDDM-non-insulin dependent)

-usually maturity onset (males > females) & most are over 40yrs / Strong family history of diabetes

-causes of NIDDM :

.decreased insulin secretion

.increased insulin resistance

-it is associated with obesity and lack of exercise and calorie excess

+Type 1DM ____________________________ Type 2DM

.younger Pt .older Pt

.HLA-D3 & D4 linked .no HLA assoc.

.autoimmune beta cell destru. .Insulin resis. ,beta cell dysf.

.polydipsia,polyuria,weight loss,ketoacidosis. .often asymptomatic,present with micro- or

macrovascular complications.

-Symptoms of hyperglycaemia :

.polyuria

.polydipsia

.unexplained weight loss

.visual blurring

.genital thrush

.lethargy

.random glucose of >200mg/dl

.acute metabolic decompensation,resulting in coma (ketoacidosis for IDDM,hyperosmolar coma for NIDDM)

- Complications of DM :

.Background retinopathy

.Cataracts

.Mononeuritis multiplex

.impotence

.6th cranial nerve palsy

.Albuminuria

.Painful neuropathy

.DKA

+Other causes of DM :

.drug induced “steroids,thiazides”

.pancreatic “pancreatitis;surgery where pancreas is removed;trauma;cystic fibrosis;pancreatic cancer”

.endocrine “cushing`s disease;acromegaly;phaeochromocytoma;hyperthyroidism”

.others “Acanthosis nigricans;glycogen storage diseases”

+Other categories of DM :

.impaired glucose tolerance IGT (fasting plazma glucose <7mmol/L & OGTT 2h glucose >7.8mmol/L)

.impaired fasting glucose IFG (fasting plazma glucose >6.1mmol/L)

+Causes of insulin resistance IR (is a physiological condition in which cells fail to respond to the normal actions of the hormone insulin) :

.obesity .werner`s syndrome

.pregnancy .polycystic ovarian sundrome

.acromegaly .metabolic syndrome

.cystic fibrosis

.TB drugs

.cushing`s

**Diabetic nephropathy (or diabetic kidney disease) is a progressive kidney disease caused by damage to the capillaries in the kidneys glomeruli.

-Symptoms can take 5 to 10 years to appear after the kidney damage begins,include :

.severe tiredness

.headaches

.general feeling of illness

.nausea, vomiting

.lack of appetite

.itchy skin

.leg swelling

-Causes :

.Poor control of blood glucose

.High blood pressure

.Type 1 diabetes mellitus (before age 20)

.History of cigarette smoking

.A family history of kidney problems

-Diagnosis :

.urinary albumin excretion <30 mg/24h;

-Treatment :

.ACE inhibitor medications (for hypertension)

Diabetic Ketoacidosis

-Is a result of severe insulin insufficiency.It is assciated with hyperkalemia.It occur in type 1 diabetics may be the presenting manifestation,May occur in type II diabetes (insulin independent) but very rare.

-May be precipitated by infection,surgery,MI,wrong insulin dose.

-The diagnosis requires ketosis and acidosis (pH<7.3) / The diagnosis can be made by finding elevated blood glucose,incresed serum levels of acetoacetate,acetone,and hydroxybuyrate,metabolic acidosis,and increased anion gap. (Total body potassium is high is false)

-Signs & Symptoms :

.polyuria .hypervetilation

.polydispia .ketotic breath

.lethargy .dehydration

.anorexia .vomiting,abdominal pain,com

-Investigations:

.lab glucose,blood cultures

.urine tests “ketones”

-Comlications :

.cerebral edema

.aspiration pneumonia

.hypokalaemia

.hypomagnesaemia

.hypophosphataemia

.hypoglycaemia

.hyponatrimia

.thromboembolism

.hyperosmolar non-ketotic coma

.Increased anion gap

.Pseudohyponatremia

.Paco2 decreased

.PH decreased

.leukocytosis

-Treatment :

.Give K

.Monitor intake – output

.Correct acidosis when pH is less than 7.1

.Monitoring ketones in the blood is more important than in urine

.Heparin may be used prophylactically

+Anti-glutamic acid decarboxylase (GAD) antibodies (Anti-GAD antibodies are usually positive in DM type1)

+Diabetes may be secondary to :

.Pheochromocytoma

.Glucagonoma

.Cushing's syndrome

.Thiazide therapy

.Acromegaly

.Pancreatic carcinoma

+ hypoglycemic agents :

.Glibenclamide

.Chlorpropamide

.Gliclazide

.Ghlorpromazine

.Glipizide

+ There is an association between the use of biguanide oral hypoglycemia agent metformin (Glucophage) and the development of (Lactic acidosis)

Hypoglycemia

-This is the commonest endocrine emergency

-brain damage & death can occur in severe prolonged cases

-Symptoms :

.sweating

.drowsiness

.seizures

.coma

.tremor

.palpitation

-Causes :

.Insulinoma

.Hypoadrenalism

.Paracetamol overdose

.Alcohol

.Postprandial

.Hepatic failure

.Glibenclamide therapy

.Addison's disease

*Fasting hypoglycaemia

-Causes (EXPLAIN)

.Exogenous drugs

.Pituitary insufficiency

.Liver failure (enzyme defects)

.Addison`s disease

.Islet cel tumours (insulinoma,hodgkin`s disease)

.Non-pancreatic neoplasms

.hyperinsulinism (can occur secondary to insulinoma)

*Post-prandial hypoglycaemia

-may occur after gastric surgery and in tyoe 2 diabetes

Insulinoma

-Pancreatic B-cell tumor and associated with MEN-1,can cause hypoglycemia-benign tumors / it presents as fasting hypoglycaemia with wipple`s traid

-Clinical findings :

.include symptoms of subcute or chronic hypoglycemia

.blurred vision

.headache

.feeling of detachment

.slurred speech

.weakness

.symptoms occur in the early morning or late afternoon or after fasting or exercise

-Diagnosis :

.This is made by finding a serum insulin level of 8 mg/mL or more in the presence of blood glucose values <40 mg/dL

.CT scan,U/S and arteriography may also be useful in detecting the tumors

-Treatment :

.surgical excision

Glucagonoma

-Glucagonoma are rare tumor of the alpha cells of the pancreas

-DM is present in 80-90% of cases of glucagonoma (not responding to insulin)

**Thyroid Function Test (TFTs)

-Hypothyroidism (inc. TSH – dec. T4.T3)

-Hyperthyroidism (dec. TSH –inc. T4.T3)

-Subclinical hypothyroidism (inc. TSH –normal T4.T3)

-Subclinical hyperthyroidism (dec.TSH –normal T4.T3)

+The most sensitive indicator of primary hypothyroidism is TSH (thyroid-stimulating hormone)

**Hyperthyroidism (Thyrotoxicosis)

-Can result from excess production of TSH “rare” or abnormal thyroid stimulators.Amiodarone can induce thyrotoxicosis

-Weight loss despite inreased appetite

-heat intolerance,sweating,diarrhoe,tremor,irritability,emotional lability,itch,oligomenorrhoe-may cause infertility

Graves` disease

-M.C.C of hyperthyroidism in Pt under age 50yrs / TSH is low

-This is autoimmune disease caused by stimulatory TSH-receptor antibodies.It is associated with other autoimmune disease (vitiligo,type 1 DM,addison`s disease)

*Toxic adenoma

-Can result from a hyperfunctioning adenoma (toxic)

*Toxic multinodular goitre

-Is non-autoimmune disease of the elderly associated commonly woth arrhythmia and congestive heart failure (CHF) and sometimes the simple goiter

*Ectopic thyroid tissue

-Metastatic follicular thyroid cancer (choriocarcinoma or struma ovarii)

-About Grave's disease (thyrotoxicosis) :

.inc. pulse

.tremor

.palmar erythema

.hair thinning

.lid lag

.lid retraction

.goitre

.eye disease (may be the 1^st sign of G.d - exophthalmus)

.pretibial myxoedema

.oedematous swellins

.above lateral malleoli

.thyroid acropachy (clubbing,painful finger and toe swelling)

.dec. TSH / T4-T3 inc.

.mild normocytic anaemia

.leucopenia,Ca inc.,LFT inc.

.myopathy may occur

.atrial fibrillation

.oligomenorrhea

.tachycardia

.excessive warm sweating

.nervousness

-Treatment of thyrotoxicosis :

.Neomercazole

.Radioactive iodine

.Surgery

.Propranolol inderal

.Carbimazole

.Potassium perchlorate

.Propranolol

+Cyclophosphamide is NOT

-Diff. Diagnosis :

.acromegaly

.neurosis,anxiety

.pheochromocytoma

.cardiac disease

.ophthalmoplegia and exophtha;mus

-Complications :

.heart failure (thyrotoxic cardiomyopathy)

.angina

.osteoporosis

.ophthalmopathy

.gynaecomastia

.thyroid storm

Thyroid Storm

-Is a rare but severe and potentially life-threatening complication of hyperthyroidism (overactivity of the thyroid gland)

-It is characterized by :

.high fever (often above 40°C/104°F)

.fast and often irregular heart beat (tachycardia)

.vomiting, diarrhea and agitation

.heart failure may occur, and myocardial infarction is encountered

.jaundice,dehydration,hyotension

.death may occur despite treatment

.high T3.T4

.coma

-It is precipitated by stress,surgery or trauma

**Hypothyroidism (myxoedema)

-Primary hyoithyroidism can occur secondary to chroinic thyroiditis (Hashimoto disease);this is the M.C.C of goitrus hypothyroidism

-Symptoms & Signs :

.tiredness .cerebral ataxia

.dry skin and hair .weight gain

.non-pitting oedema .constipation

.carpal tunnel syndrome .poor congition

.menorrhagia .hoarse voice .peripheral neuropathy .bradycardia,hyponatremia & anemia

.myalgia,dementia .in the newborn sings include cretinism

.toad-like face.appetite decreases and weight increases .pleural effusion

.lethargy .deafness

.depression .periorbital puffiness

.Pericardial effusion

.dislike of cold

-Diagnosis :

.in primary (inc.TSH – dec. T4)

.in secondary (dec. or normal TSH – dec.T4)

-Causes :

.primary hypothyroidism (lymphocytic infiltration of the thyroid)

.hashimoto`s thyroiditis

.iodine deficiency

.secondary hypothyroidism (from hypopituitarism ) is very rare

-Associations :

.turner`s syndrome

.down`s syndrome

.cystic fibrosis

.primary biliry cirrhosis

Date: 2016-04-22; view: 523