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  1. 1. By Dr Ashok Jaisingani
  2. 2. It is a chronic systemic clinical syndrome , which ischaracterized by hyperglycemia that reflect to either lackof the insulin or there is peripheral resistance to insulin.As a result there is elevation of the serum glucose level,the consequence of the elevated glucose level is that thereis non – enzymatic glycosylation of the protein that havelot of the pathology of the diabetes
  3. 3. The Prevalence Of the diabetes is 2 – 3%
  4. 4. Diabetes mellitus is diagnosed by there is elevation of the fastingglucose level more than 126 on two separate occasionOrThere glucose tolerance test (GTT) is positiveThese can make the diagnosis
  5. 5. There are two types-Primary diabetes mellitus-Secondary diabetes mellitus
  6. 6. Primary Diabetes mellitus is categorized as1) Type I DM it is also called as insulin dependant diabetesmellitus IDDM2) Type II DM it is also called as non – insulin dependantdiabetes mellitus NIDDMThe most common is type II DM (about 90 – 95% of thecases)
  7. 7. The Diabetes mellitus is secondary to other diseases such as1) Pancreatic Disease2) Endocrine Disease3) Drug – Induced Diabetes4) Associated With The Genetic Syndrome5) Gestational Diabetes
  8. 8.  Pancreatitis Hemochromatosis Cystic Fibrosis Pancreactomy
  9. 9.  Cushing Syndrome Acromegaly Thyrotoxicosis Pheochromocytoma Glucagonoma
  10. 10. Following Drugs May causing The Diabetes Corticosteroid Therapy Thiazide Diuretics Phenytoin
  11. 11.  Freidreich Syndrome Myotonic Dystrophy Down’s Syndrome Klinefelter’s Syndrome Turner’s Syndrome
  12. 12. Pregnancy induced Diabetes
  13. 13. Definition:There is absolute lack of the insulin due to autoimmunedestruction beta cellsIt accounts for about 5 – 10% of the diabetes mellitusIt is most common in children & adolescence usually below theage of the 20The peak age of the occurrence of the type I diabetes is 10 – 13years of the age
  14. 14. Person who have Northern European ancestors- HLA System: (HLA DR 3, 4 & DQ)- Genetic Susceptibility- Inheritance (child of insulin dependent diabetes have increasechances)- Viral Infection (Coxsackie’s virus B4)- Pancreatic Pathology- Immunological Factors (T – cell mediated immune disease)
  15. 15. Islet autoantibodies are appears in the circulation in the firstfew year of the life in first degree relatives of type I diabetesdemonstrating that the process culminating in diabetes isinitiated very early and many year before the diagnosis
  16. 16. There is absolute lack of the insulin because of autoimmunedestruction of the islets beta cellsAs a result these persons are totally depend on insulinWith out insulin they develop theDiabetic KetoacidosisComa
  17. 17. The autoimmune destruction of the beta cells is triggered by theinfection & certain environmental factors in genetic susceptibleindividualsAs a result beta – cells destroyed  insulin production becomestop  there is absolute lack of the insulin  the pts not able usethe glucose  their serum glucose level is elevated
  18. 18. On biopsy there is lot of the lymphocytes infiltration withinthe pancreas surround the islets cells so called as “insulitis”There is gradually loss of the beta cells and produce fibrosisultimately these person develop diabetes mellitus
  19. 19. Most of these pts are present with the 3P*Polyuria*Polyphagia*Polydipasia Other Features:-Weight Loss-Blurring Of The Vision- Postural hypotension & Paraethiasis- KetoacidosisThere is also electrolytes imbalance  dehydration metabolic ketoacidosis  coma  deathThese Pts totally depend on insulin injection
  20. 20. It is most common type of the diabetes mellitusIt accounts for about 90 – 95% of the casesIt is most common in individual age above 30It is most common in obese individual, there is peripheralresistance to insulinInitially there may be increase serum insulin levelType II diabetes mellitus is silence disease because world widehalf of the cases of type II DM are undiagnosed
  21. 21. - Obesity- Genetic susceptible individual (Positive family history)- Environmental factors- Old age
  22. 22. It is rare variant of the type – 2 diabetes mellitus and isstrongly inherited.The disease should be suspected in young peoples presentingwith a typical family history and in whom other features ofthe type 1 are lacking
  23. 23. There is reduction of the insulin secretionBut most important is that there is peripheral resistance to theinsulin, peripherally there is decrease tissues sensation to theinsulinMicroscopic Appearance:Microscopically there is non – specific changes in pancreasThere is little bit atrophyAmyloid deposition
  24. 24. Frequently the pts with the type II diabetes are asymptomaticThey also develop 3PPolyuriaPolyphagiaPolydipasiaLack Of The EnergyDelayed Wound HealingBlurring Of The VisionFungal infection (Pruritis vulvae, Balanitis)Finally they also develop coma but this time there is“Hyperosmolar non – ketotic diabetic coma
  25. 25. Major organs affected in diabetes are following-Vascular system (Microangiopathy)-Kidney (Nephropathy)-Eye (Retinopathy)-Peripheral (Neuropathy)-There is increase risk of the infection-Diabetic Foot
  26. 26. Diabetes mellitus is a major risk factor for the development of theatherosclerosisMost of the diabetes pts are die because of the MI (No. 1 killer)There is also development of the peripheral vascular diseaseSmall Vessels: (microvascular disease)There is thickening of the basement membrane and hyalinearteriolar sclerosisOther causes of the hyaline arteriolar sclerosis in small vessels are-Hypertension-Aging
  27. 27. There is development of the renal artery atherosclerosis as a resultlumen become narrow (stenosis)In small vessels there is hyaline sclerosis changesThere is granular appearance on the surface of the kidneyGlomerular Diseases In DM:Two most common glomerular diseases*Diffuse glomerular sclerosis (Nephrotic syndrome)*Nodular glomerular sclerosis (Kimmelstiel-Wilson lesion)There is thickening of the basement membraneNephrotic SyndromeThere is also increase risk for the development of thepyelonephritis, necrotizing papilitis & ultimately renal failure
  28. 28. There is tremendous amount of the pathology in the retina1) Non – proliferative phase:There is development of the microaneurysm in retinal vessel these become rupture  retinal hemorrhage & retinal exudateAs a consequence of the retinal hemorrhage there is developmentof the new vessels (neovascularization) & fibroblast growth thusgranulation tissues formation2) Fibrotic Phase: There is formation of the scar  over the timethe scar become contract and pull the retina  blindnessThere is also increase risk of the development of the cataract &glaucoma as well
  29. 29. Lower Extremities:Peripheral neuropathyNon – healed ulcer (There is non – traumatic ulcer indiabetic patients)Focal neurologic impairment is most likely due to themicrangiopathyBladder:Neurogenic bladderIncrease risk of the development of theCystitisPyelonephritis
  30. 30. Diabetes Pts develop one special type of the infectionThe infection is caused by the fungus mucor mycosisThere is necrotizing infection of the sinuses the problemwith that there is increase chances of the transformation ofthe infection to the brain that cause very seriouscomplication
  31. 31. -Fasting Blood Sugar (FBS)-Random Blood Sugar (RBS)-Glucose Tolerance Test (GTT)-Glycosylated Hemoglobin (Hemoglobin A1c)-Serum Fructosamine-Urinalysis to detect glucose in the urine-Urine For Proteinuria-Complete Blood Count (CBC)-Urea, Creatinine & Electrolytes-Fasting Serum Cholesterol & Triglyceride
  32. 32. Normal Fasting Glucose level is less the 110mg/dlImpaired fasting Glucose is >110 but < 126 mg/dlIf fasting blood sugar is greater than 126mg/dl on more thanone occasion, diabetes is confirmed
  33. 33. If random blood sugar is greater than 200 mg/dl on twoseparate occasion, the diabetes is confirmed, however themore reliable test is FBS
  34. 34. After the overnight fast, 75 gm of the glucose is taken in 250– 300 ml of the waterNormally 2 – hour after the glucose load is < 140 mg/dlImpaired glucose tolerance test is labeled, when 2 – hourafter glucose is > 140mg/dl but < 200 mg/dlDiabetes is confirmed if two hours after glucose is > 200mg/dl- GTT is confirmatory test, require only when the FBSglucose level is greater than normal
  35. 35. Level of the glycosylated HB reflect the state of theglycemia over the preceding 8 – 12 weeksNormal level is 4 – 6%Therapy is require when the HB A1c is above the normalThe sensitivity of the test is about 85%The test is quite is specific in 91% of the cases
  36. 36. Serum fructosamine is formed by nonenzymaticglycosylation of the serum protein predominantly thealbuminSerum fructosamine level reflect the state of the glycemiccontrol for preceding 2 weeks.Normal values are 1.5 – 2.4 mmol/L
  37. 37. Strips are used for detection of the glucose inthe urine
  38. 38. Type I:- Diet Modification- Insulin InjectionType II:- Oral hypoglycemic AgentsSulphonylureas (Thin pts)Biguanides (Obese Pts)Oral hypoglycemic agents are contraindicated in pregnancyVascular complication of the diabetes can be reduced by thelow dose aspirin
  39. 39. - Modification Of The Diet- Reduction Of The Weight- Diet & Oral Hypoglycemic Agents- Diet & Oral hypoglycemic Agents
  40. 40. -Fasting Blood Sugar (FBS)-Random Blood Sugar (RBS)-Glucose Tolerance Test (GTT)-Glycosylated Hemoglobin (Hemoglobin A1c)-Serum Fructosamine-Urinalysis to detect glucose in the urine-Urine For Proteinuria-Complete Blood Count (CBC)-Urea, Creatinine & Electrolytes-Fasting Serum Cholesterol & Triglyceride
  41. 41. Achieve Good Glycemic ControlReduce Hyperglycemia & Avoid HypoglycemiaAssist With The Weight managementReduce The Risk Of The Micro & macrovascularcomplicationEnsure The adequate nutrition intakeAvoid the athrogenic diet or those that aggravatecomplication (e.g. High protein intake in nephropathy)
  42. 42. Carbohydrate: ( 45 – 60%)Sucrose up to 10%Fat: (< 35%)n – 6 polyunsaturated < 10%n – 3 Polyunsaturated (eat oily fish once or twice weekly)Monounsaturated 10 – 20%Saturated < 10%Protein: (10 – 15%)Protein do not exceed 1g/kg of the body weight
  43. 43. In patient with the diabetes the weight management is keyfactor as a high percentage of the peoples with the type IIdiabetes are obese or overweightmany anti – diabetic medication and insulin encourageweight gainAbdominal obesity with increase waist circumference alsopredict insulin resistance and CVS riskWeight loss can be achieved through a reduction in energyintake and an increase in energy expenditure throughphysical activity
  44. 44. Alcohol can be consumed in moderation unless there is a co– existing medical problem that require abstinenceAlcohol precipitate the hypoglycemia particularly in patientstaking insulin or sulphonylureas because alcohol inhibit thegluconeogenesis
  45. 45. Peoples With diabetes should follow the advice given to thegeneral populationReduce sodium intake to no more than 6 – g/dayFurther restriction of the sodium intake 3 g/day is important intreating hypertensive diabetic patient
  46. 46. Low – calories and sugar free drinks are useful for patientwith the diabetesThese drinks usually contain non – nutritive sweetenersmany diabetes foods are contain sarbitol and are expensive,high in calories and may cause the gastrointestinal side –effects
  47. 47. Various drugs are effective in reducing the hyperglycemia inpatient with the type – II diabetes such as- Sulphonylureas- Biguanides- Alpha – Glucosidase Inhibitors- Thiazolidinediones- Meglitinides & Amino Acids derivatives- Combined Oral anti – diabetic therapy & Insulin
  48. 48. Thanks For Watching This Presentation