CPD Endocrine Review: Pancreas
What is the pancreas' main function?
exocrine digestive enzymes, amylase and lipase
delivered to duodenum via pancreatic and common bile duct
One out of every seven healthcare dollars is spent on what medical condition?
diabetes mellitus
What's the clasic presentation of diabetes mellitus?
polyuria
polydipsia
polyphagia
What are the two metabolic defects that characterize type 2 diabetes?
insulin resistance esp in skeletal muscle and fat
beta cell dysfunction-->inadequate insulin production in the face of defect #1
What is LADA?
Latent autoimmune diabetes in adults
aka type 1.5, type 3 or slow onset
seems to be AI but presents in 30-40's
and pts are hyperglycemic but not overweight or insulin resistant ???
cow milk implicated in autoimmune rxn
GAD65 Ab's
What can cause secondary diabetes mellitus?
hemochromatosis
recurrent or chronic pancreatitis
trauma
drugs (prednisone & other corticosteroids, alpha-interferon, dilantin and the protease inhibitos contribute to increased hepatic glucose production and/or increased insulin release)
pregnancy
When does gestational diabetes usually begin?
late in the second trimester
What are the risk factors for gestational diabetes?
obesity
family hx of type II dm
older mother
The infant of a mother with insulin resistance faces what challenges?
they'll have too much insulin at first and be hypoglycemic
very dangerous if extreme
infant may have large head and shoulders
What are the official diagnostic criteria for DM?
confirmed fasting serum glucose >126 mg/dL
nonfasting >200 mg/dL
positive OGTT >200 2-3 hours post glucose bolus
finger stick not sufficient for dx
HGB A1C not listed dt cost
urine glucose spillage threshold varies so urine not diagnostic, lower in kids, pregnancy
What are the potential complications of diabetes mellitus?
MI
stroke
renal disease
CAD, anginga
HTN, claudication
skin ulcers, gangrene, necrobiosis lipoidica diabeticorum, acanthosis nigricans
skin atrophy, diabetic ulcers
shin spots, bullae, eruptive xanthomas
incr herpes zoster
fungus local or systemic
retinopathy: cataracts, refraction changes, retinal detachment
keratitis, blindness
neuropathy: paresthesias, cranial nerve palsies
autonomic nerve palsies, orthostatis hypotension
loss of normal pain and temperature sensation
nephropathy
Charcot's disease
What are AGEs?
advanced glycosylated end products
hyperglycemia sticks sugars onto proteins then they don't work right
What are some other mechanisms for diabetic pathogenesis?
increased vascular permeability
increased oxidative stress
zinc, magnesium and other nutritional deficiencies
possible iron overload even without hemochromatosis gene
SORBITOL BUILDUP
Where does sorbitol build up?
nerves, retina, glomeruli
these cells don't need insulin for glucose uptake
sorbitol and fructose are glucose byproducts caused by enzyme aldose reductase
What might you see in a diabetic on opthalmoscopic exam
lipid deposits
neovascularization
What's the difference between diabetic ketoacidosis and non-ketotic hyperosmolar coma?
ETIOLOGY:
DKA: insulin def and high epi
nonketot: inadequate fluid intake and high sugar
SIGNS AND SYMPTOMS:
DKA: vomiting, hyperglycemia
non-ketot: lethargy, obtundation, extreme hyperglycemia >1800 mg/dl, dehydration
What causes DKA?
total or near total insulin deficiency
elevated epinephrine
more common in type 1 but occurs in type 2 when physiologically stressed (ex: acute infx)
What are the signs and symptoms of DKA?
nausea, vomiting
suspect if vomiting 1-2 days
hyperglycemia
high levels of circulating ketone bodies-->acidosis
early: flushed, radid/deep breathing
late: dehydration, shallow breathing, ketotic breath, rapid heart rate-->coma
What is the principle symptom of nonketotic hyperosmolar coma?
lethargy
What's the most common reason for hypoglycemic coma?
excess administration of exogenous insulin
incl sulfonylureas (oral)
Tx: glucagon or IV glucose
exocrine digestive enzymes, amylase and lipase
delivered to duodenum via pancreatic and common bile duct
One out of every seven healthcare dollars is spent on what medical condition?
diabetes mellitus
What's the clasic presentation of diabetes mellitus?
polyuria
polydipsia
polyphagia
What are the two metabolic defects that characterize type 2 diabetes?
insulin resistance esp in skeletal muscle and fat
beta cell dysfunction-->inadequate insulin production in the face of defect #1
What is LADA?
Latent autoimmune diabetes in adults
aka type 1.5, type 3 or slow onset
seems to be AI but presents in 30-40's
and pts are hyperglycemic but not overweight or insulin resistant ???
cow milk implicated in autoimmune rxn
GAD65 Ab's
What can cause secondary diabetes mellitus?
hemochromatosis
recurrent or chronic pancreatitis
trauma
drugs (prednisone & other corticosteroids, alpha-interferon, dilantin and the protease inhibitos contribute to increased hepatic glucose production and/or increased insulin release)
pregnancy
When does gestational diabetes usually begin?
late in the second trimester
What are the risk factors for gestational diabetes?
obesity
family hx of type II dm
older mother
The infant of a mother with insulin resistance faces what challenges?
they'll have too much insulin at first and be hypoglycemic
very dangerous if extreme
infant may have large head and shoulders
What are the official diagnostic criteria for DM?
confirmed fasting serum glucose >126 mg/dL
nonfasting >200 mg/dL
positive OGTT >200 2-3 hours post glucose bolus
finger stick not sufficient for dx
HGB A1C not listed dt cost
urine glucose spillage threshold varies so urine not diagnostic, lower in kids, pregnancy
What are the potential complications of diabetes mellitus?
MI
stroke
renal disease
CAD, anginga
HTN, claudication
skin ulcers, gangrene, necrobiosis lipoidica diabeticorum, acanthosis nigricans
skin atrophy, diabetic ulcers
shin spots, bullae, eruptive xanthomas
incr herpes zoster
fungus local or systemic
retinopathy: cataracts, refraction changes, retinal detachment
keratitis, blindness
neuropathy: paresthesias, cranial nerve palsies
autonomic nerve palsies, orthostatis hypotension
loss of normal pain and temperature sensation
nephropathy
Charcot's disease
What are AGEs?
advanced glycosylated end products
hyperglycemia sticks sugars onto proteins then they don't work right
What are some other mechanisms for diabetic pathogenesis?
increased vascular permeability
increased oxidative stress
zinc, magnesium and other nutritional deficiencies
possible iron overload even without hemochromatosis gene
SORBITOL BUILDUP
Where does sorbitol build up?
nerves, retina, glomeruli
these cells don't need insulin for glucose uptake
sorbitol and fructose are glucose byproducts caused by enzyme aldose reductase
What might you see in a diabetic on opthalmoscopic exam
lipid deposits
neovascularization
What's the difference between diabetic ketoacidosis and non-ketotic hyperosmolar coma?
ETIOLOGY:
DKA: insulin def and high epi
nonketot: inadequate fluid intake and high sugar
SIGNS AND SYMPTOMS:
DKA: vomiting, hyperglycemia
non-ketot: lethargy, obtundation, extreme hyperglycemia >1800 mg/dl, dehydration
What causes DKA?
total or near total insulin deficiency
elevated epinephrine
more common in type 1 but occurs in type 2 when physiologically stressed (ex: acute infx)
What are the signs and symptoms of DKA?
nausea, vomiting
suspect if vomiting 1-2 days
hyperglycemia
high levels of circulating ketone bodies-->acidosis
early: flushed, radid/deep breathing
late: dehydration, shallow breathing, ketotic breath, rapid heart rate-->coma
What is the principle symptom of nonketotic hyperosmolar coma?
lethargy
What's the most common reason for hypoglycemic coma?
excess administration of exogenous insulin
incl sulfonylureas (oral)
Tx: glucagon or IV glucose