Dm1.mansfans.com

Diabetes Mellitus By Prof. Dr. Nabil Lymon Professor of Internal Medicine Mansoura University Faculty of Medicine

DEFINITION 



It is a clinical syndrome Characterized by : 

Chronic persistent hyperglycemia.



Disturbed metabolism of Ptn , Fat, CHO & Electrolyte.



Microangiopathy esp. in Retina, Glomeruli, & vase nervosa.

It is caused by: ( absolute or relative lack of insulin )

www.MansFans.co

CLASSIFICATION OF DM 1.

Type I diabetes A. Immune mediated B. Idiopathic

2. 3. 4.

Type 2 diabetes Gestational DM Other specific types: A. B. C.

Genetic defects of B-cell function Genetic defects in insulin action Exocrine pancreatic causes 1. 2. 3.

Congenital cystic fibrosis Chronic pancreatitis, Hemochromatosis Fibrocalculus pancreatopathy (tropical DM tropical malnutrition)

www.MansFans.co

A.

B.

  

Endocrinal causes 1. Acromegaly, Pheochromocytoma 2. Cushing syndrome, Conn's syndrome 3. Somatostatinoma Glucagonoma, 4. Thyrotoxicosis Infections:  congenital rubella  cytomegallovirus Drugs : a- interferon, Corticosteroids , CCP Other genetic syndromes: Down's syndrome - Klinefelter syndrome Uncommon forms of immune mediated diabetes: anti-insulin receptor Ab

N.B: ** (MODY type): Mature Onset Diabetes in the Young: - Represent 15 % of cases, autosomal dominant, in young obese people -Treated by oral antidiabetics, less liable for microangiopathy ** ( LADA ): (Late onset Autoimmune Diabetes of Adult)

Diagnosis of DM Complication

C/P 

Investigation

CLINICAL PICTURE  

Asvmptomatic: in 1/3 of cases Classic symptoms: 1. 2. 3. 4. 5. 6. 7.



Polyuria : with nocturia Polydypsia Polyphagia with weight loss Pruritis especially of vulva Pains & paresthesia Premature loosening of teeth Blurred vision : due to osmotic swelling of lens

Symptoms of complications: acute, chronic.

DD

Complication of DM Acute complications 2. Diabetic comas. 3. Infections. 4. Complication related to systems.  ARF.  AMI.  Acute neuropathy

            

www.MansFans.com

Chronic Complication Neurological compl. Ocular Complication. CVS complication . Pul. complication GIT complication. Renal complication Genital complication. Skin complication. Diabetic Foot. Rheumatological comp Infection Psychiatric complication comp. of therapy

Differential Diagnosis A) D.D. of reducing substance in urine 1. Glucosuria 1. Renal glucosuria due to Low renal threshold:  Pregnancy  De-Toni Fanconi syndrome 2. Alimetary glycosuria: Gastrectomy, liver cirrhosis 3. Cerebral glucosuria : Sub arachinoid hge , Meningitis 2. Other Sugar in urine : Fructosuria , galactosuria, pentosuria 3. Other Reducing substances in urine : Vit.C , salicylates

B). D.D. of symptomatology 1.

loss of weight inspite of good appetite: - Malabsorption syndrome - Parasitic infestation - Thyrotoxicosis



Other causes of Polyuria

C). 1ry from 2rv DM : (Cushing disease) D). Type 1 DM from Type 2 DM:

www.MansFans.co

Type I DM = (IDDM)

Type 2= (NIDDM)

Incidence

5-15%

85%

Subtypes

Type I A : 80 % immune Type I B : 20 % idiopathic

Type 2-obese: 80 Type 2-non obese : 20

Genetic locus

Chromosome 6 - recessive HALA DR3, DR4,B8,B15,

Chromosome 11 - multifactorial absent

Pathogenesis

See before

See before

Age of onset

< 30 years

> 30 years

sudden

Gradual

Severe, including coma

May be no symptoms

Ketolabile

Ketoresistant

onset symptoms Complication (DKA)

Investigation Treatment

Insulin

Low or absent

Glucagon

High and suppressed by insulin

Auto Ab

ICA, ICSA, Anti-GAD

C-peptide

deficient Insulin is a must

- Abnormal - ↑↑ insulin resistance High and resistant to insulin Absent increased -Diet - OHD ± insulin

Investigations A- To diagnose DM Plasma glucose

Normal (mg/dl) Prediabetes (IGT)

diabetes

Random (casual)

< 200mg

--

> 200+ polys

Fasting

70 - 100

100-125 (IFG)

> 126

2 hr. PP

<140

140 -199 (IGT)

> 200





IFG: "Impaired fasting glucose" 100 - 125 mg IGT: "Impaired glucose tolerance"- 2h. P.P. 140 -199 mg

IGT Personnel: (rule of third)

1/3 remain IGT 1/3 develop frank DM, 1/3 return to normal plasma glucose

B- To diagnose type of DM 1.

Plasma insulin level 

2. 3.

C -peptide level : assess endogenous insulin secretion Auto antibodies:   

4.

it is low in type 1 DM & show early rise in type 2 DM

Anti insulin receptorAb in immune mediated type 1 DM. Anti GAD (glutamic acid decarboxylase) ICA

For the cause 

If 2 dry DM is suspected e.g. Cushing syndrome.

C- To monitor diabetic patients    

Retinopathy : Fundus Exam. Nephropathy : urine analysis for microalbuminuria ECG Lipid profile

www.MansFans.co

D- To monitor diabetic patients  BLOOD: 1.

Glvcosvlated proteins a- Hb A1c: Target in diabetics: < 7%  Formed due to non-enzymatic glycosylation of amino acid valine & lysine in β chain of HbA  Its % gives an estimate of diabetic control for the preceding 3 months.  The Normal level 4 - 6 % of total Hb

b- Other glycosylated proteins: fructosamine (glycosylated albumin) Factors interfering with measurement of A1c. a- False high values: uremia, high concentrations of fetal hemoglobin (HbF), high aspirin doses (usually>10 g/day), or high concentrations of ethanol. b- False low values: hemogloinopathies, hemorrhage and hemolytic disorders.

www.MansFans.co

Thank You

www.MansFans.co