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diabetes mellitus document

  1. 1. Diabetes mellitus by Najiur Ruman 1. Introduction: Diabetes mellitus is a clinical syndrome characterized by the hyperglycemia due to absolute or relative deficiency of insulin , i.e due to either A deficiency are insulin secretion or a combination of insulin resistance and inadequate insulin secretion to compensate. diabetes is the most common endocrine disorder. It affects almost all the system of the human body since lack of insulin affect metabolism of carbohydrate protein and fat and also causes a significant disturbance in water and electrolyte balance. 2. Classification of diabetes mellitus: A. Type 1( insulin dependent Diabetes mellitus IDDM ) 1. immune mediated 2. Idiopathic B. type 2 (non insulin dependent Diabetes mellitus NIDDM) 1. Non obese type 2 2. Obose type 2 C. Other specific types of diabetes 1. genetic defects of pancreatic Beta cell function a. maturity onset diabetes of young MOD Y 1-6 . A rare subgroup, Belongs two type 2 diabetes b. Diabetes mellitus associated with a mutation of mitochondrial DNA 2. genetic defects of insulin action a. type a insulin resistance b. Leprechaunism c. rabson manhandle syndrome d. lipoatrophic diabetes 3. Diabetes due to pancreatic diseases (exocrine part) 1
  2. 2. 4. Endocrinopathies (i.e execess endogenous production of hormonal antagonists to insulin) 5. Drug a chemical induced diabetes 6. Diabetes due to viral infections (e.g congential rubella, mumps, Coxackie virus B) 7. Uncommon forms of immune mediated diabetes 8. diabetes associated with the genetic syndromes ( e .g down syndromes, turner's syndrome, otic atropy, Diabetes mellitus, nerve defences, myotonic dystrophy) D. Gestational diabetes 2.1 Type 1 Diabetes mellitus Type 1 Diabetes mellitus occurs due to pancreatic beta cell destruction predominantly by i. An auto email process greater than 90% and less commonly by ii. idiopathic unknown causes less than 10%. the immune mechanism involved in Type 1 Diabetes in a slow t cell mediated auto immunity. about one third of these at due to genetic linkage with special predisposition of human Lymphocytes antigen (HLA).The particular haplotypes associate with Type 1 Diabetes are HLA-DR3 and HLA-DR4. Some viral infections also known to causes autoimmune damage to beta cells. Type 1 Diabetes occurs mainly in the Juvenile age group with highest incidence in between 10 to 14 years specially in the known of pace and rarely occurs in the adult life.It is usually associated with the ketoacidosis if not treated duly. in Type 1 Diabetes circulating insulin is almost absent plasma glucagon elevated part the pancreatic beta cell failed to respond to all insulinogenic stimauli.As a result insulin supplementation is essentially required to reverse this catabolic state reduce blood glucose prevent ketoacidosis and reduce the plasma glucagon. 2
  3. 3. 2.2 Type 2 Diabetes mellitus: Type 2 Diabetes mellitus is the most prevent from of diabetes greater than 90% ,results from insulin resistance a defect in compensatory insulin secretion.It representsheterogeneous group comprising milder forms of diabetes that occur permanently in adults (most are over 40 years)But occasionally in juveniles. in this insulin production by Beta cells a significant to prevent ketoacidosis but not adequate to prevent hyperglycemia in the face of increased needs owing to tissue insensitivity. Although in most cases of type 2 diabetes causes is and on several interrelated factors are considered responsible for developing tissue resistant to insulin and impaired beta sale response to glucose such as a living a sanitary lifestyle and the abdominal obesity in addition of eating especially fine come. With the obesity and under activity contribute to aggravate the hyperglycemia. A strong genetic influence with positive family history has also been established in developing type 2 diabetes by different epidemiologic studies. Repeated pregnancy may also contribute to cause type 2 diabetes. 3. Clinical features: 3.1 ​Presentations: 1. Many patients are first noted to have glycosuria in In the course of some routine examinations. They may have had few or no symptoms and no abnormal physical signs. 2. Some patients present with the classical symptoms of diabetes example thirst, polydipsia, polyuria, nocturia, tiredness, loss of weight, white marks on the clothing, pruritus vulvac or balanitis, impotence, myopia, and paraesthesia in the limbs. 3. Diabetes may first present as a fulminating ketoacidosis associated with an acute infection and in such cases epigastric pain and vomiting may be the presenting complaints. 4. Patient may present with symptoms due to the complications of diabetes. 3
  4. 4. 3.2 Physical signs: Cases without complications will usually show no abnormal physical signs. In some cases vulvitis or balanitis may be found. In the fulminating case the most striking features are those of dehydration. The intra ocular pressure may be obviously reduced. A rapid pulse and a low blood pressure found. Breathing may be deep and sighing in the acidotic patient , the breath is usually foetid and the stickly sweet smell of acetone may be noticeable. Apathy and confusion may be found or there may be stupor or even coma. Evidences of complications of diabetes may be noted e.g. diabetic retinopathy, diabetic neuropathy, loss of ankle jerks and impaired vibration sense in the legs. 3.3 Investigations: 1. Urine testing – (urineshould be taken 2 hours after meal) i . Glycosuria – a positive response indicates that the urinary glucose concentration exceeds 10-20 mg/100ml ii . Detection of keton bodies in urine. 2. Random blood sugar – a random blood sugar exceeding 250mg/100ml (14 mmol/l) is almost certain to diagonse diabetes. 3. Oral glucose tolerance test- a fasting glucose level avobe 120mg/100ml or a glucose level above 180mg/100ml 2 hours after glucose indicated diabetes. 4. Glycated haemoglobin becomes glycated by slow non-enzymatic ketoamine reactions between glucose and other sugars and the free amino groups on the α and β chains of hemoglobin. The major form of glycated haemoglobin (HbA​1​) is hemoglobina A​1c​ (HbA​1c​) where glucose is the carbohydrate. HbA​1c​ compries 4-6% of total glycated hemoglobin (HbA​1​). The hemoglobin A​1c​ fraction is abnormally elevated in diabetic persons with chronic hyperglycemia. The rate of formulation of HbA​1c​ is directly proportional to ambient blood glucose concentration , a rise of 1% in HbA​1c​ corresponds to an approximate average increase of 2mmol/l (36mg/dl) in blood glucose. The assesment of glycated haemoglobin provides an accurate measure of glycaemic control over a period of weeks to months in a known diabetic patient. 4
  5. 5.   4. Tests are used to diagnose diabetes and prediabetes: Health care professionals most often use the fasting plasma glucose (FPG) test or the A​1c​ test to diagnose diabetes. In some cases, they may use a random plasma glucose (RPG) test. 4.1 Fasting plasma glucose (FPG) test: The FPG blood test measures your blood glucose level at a single point in time. For the most reliable results, it is best to have this test in the morning, after you fast for at least 8 hours. Fasting means having nothing to eat or drink except sips of water. 4.2 A​1c​ test The ​A​1c​ test​ is a blood test that provides your average levels of blood glucose over the past 3 months. Other names for the A​1c​ test are hemoglobin A​1c ​, HbA​1c ​, glycated hemoglobin, and glycosylated hemoglobin test. We can eat and drink before this test. When it comes to using the A​1c​ to diagnose diabetes, the doctor will consider factors such as our age and whether we have ​anemia​ or another problem with our blood. The A​1c​ test is not accurate in people with anemia. If the ​African, Mediterranean, or Southeast Asian descent, A​1c​ test results may be falsely high or low​. The health care professional may need to order a different type of A​1c​ test. The health care professional will report A​1c​ test result as a percentage, such as an A​1c​ of 7 percent. The higher the percentage, the higher average blood glucose levels. People with diabetes also use information from the A​1c​ test to help ​manage their diabetes​. 4.3 Random plasma glucose (RPG) test: Sometimes health care professionals use the RPG test to diagnose diabetes when diabetes symptoms are present and they do not want to wait until you have fasted. You do not need to fast overnight for the RPG test. You may have this blood test at any time. 4.4 Tests are used to diagnose gestational diabetes: Pregnant women may have the glucose challenge test, the oral glucose tolerance test, or both. These tests show how well your body handles glucose. 5
  6. 6. 4.5 Glucose challenge test: If anyone pregnant and a health care professional is checking her for gestational diabetes, she may first receive the glucose challenge test. Another name for this test is the glucose screening test. In this test, a health care professional will draw her blood 1 hour after drink a sweet liquid containing glucose. She does not need to fast for this test. If her blood glucose is too high—135 to 140 or more—she may need to return for an oral glucose tolerance test while fasting. 4.6 Oral glucose tolerance test (OGTT) The OGTT measures blood glucose after fast for at least 8 hours. First, a health care professional will draw blood. Then the person will drink the liquid containing glucose. For diagnosing gestational diabetes, he will need your blood drawn every hour for 2 to 3 hours. High blood glucose levels at any two or more blood test times during the OGTT—fasting, 1 hour, 2 hours, or 3 hours—mean he has gestational diabetes. The health care team will explain what OGTT results mean. Health care professionals also can use the OGTT to diagnose type 2 diabetes and prediabetes in people who are not pregnant. The OGTT helps health care professionals detect type 2 diabetes and prediabetes better than the FPG test. However, the OGTT is a more expensive test and is not as easy to give. To diagnose type 2 diabetes and prediabetes, a health care professional will need to draw blood 1 hour after drink the liquid containing glucose and again after 2 hours. Fig.: Interpretation of OGTT 6

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