Semiology of Diabetes Mellitus

Daniel Fernando Isuhuaylas Aguirre

What is Diabetes?

• Diabetes is a group of metabolic diseasescharacterized by hyperglycemia resulting fromdefects in insulin secretion, insulin action, orboth.

Pathogenic processes involved

HYPERGLYCEMIA

Autoimmune destruction of the

β-cells of the pancreas (resistance

to insulin action)

Deficient action of insulin on target

tissues.

Inadequate insulin secretion and/or diminished tissue

responses to insulin.

β – Cell dysfunction and IR

β – Cell

dysfunction

INSULIN

RESISTANCE

Glucose

Uptake

Blood glucose FFA

Glucose

Production

insulin secretion

Lipolysis

Factors

Symptoms

• Acute, life-threatening Hyperglycemia with ketoacidosis or the nonketotic

hyperosmolar syndrome.

Polyuria Blurred vision

PolyphagiaWeight loss

Polydipsia

Long-term complications

Hypertension and abnormalities of

lipoprotein metabolism

Atheroscleroticcardiovascular,

peripheralarterial, and

cerebrovascular disease.

Long-term complications

• Loss of vision

Retinopathy

• Renal Failure

Nephropathy

• Risk of foot ulcers, amputations, and Charcot joints

Peripheral neuropathy

• Gastrointestinal, genitourinary, and cardiovascular symptoms and sexual dysfunction

Autonomic neuropathy

Criteria for the diagnosis of diabetes

Natural progressionNormal IGT DM2

Fasting plasma glucose Insulin Sensitivity Insulin Secretion

Insulin sensitivity

Normal insulin secretion

Normoglycemia

Hyperglicemia

β-cell failure

Insulin resistance

DM2 + Long-termcomplications

insulin resistance

Long-term complications

• Macroangiopathy

• Microangiopathy

• Neuropathy

CVD

Cerebrovascular Disease

Vascular disease of the lower limbs

Symmetric sensory polyneuropathy

Mononeuropathy

Autonomic neuropathy

Retinopathy

Nephropathy

• Diabetic Foot

Long-term complications

• biochemicalalterations

• functional alterationsREVERSIBLE

STAGE

• Structural alterationsIRREVERSIBLE STAGES

Diabetic Nephropathy

GENETICS HYPERGLYCEMIA

Diabetic Nephropathy

DIABETES MELLITUS

THICKENING CAPILLARY

BASAL GLOMERULAR

EXPANSION OF THE

MATRIX

↑ PRESSURE

MEMBRANE

Stages

• Hyperfiltration and renal hypertrophy

• Normoalbuminuria

• Incipient diabetic nephropathy:microalbuminuria

• Clinical Diabetic Nephropathy: Proteinuria

• End Stage Renal Disease

Diabetic RetinopathyFUNCTIONAL AND

MORPHOLOGICALNS

HEMODYNAMIC ALTERATIO

HYPERGLYCEMIA

LOST PERICYTES

VASODILATION OF CAPILLARIES

BASAL MEMBRANE ALTERATION

LOSS OF ENDOTHELIAL

acellular capillaries

Hypoxia

↑VPF VEGF

Neoformation CAPILLARIES

RD NO PROLIFERATIVE

RD PRE PROLIFERATIVE

RD PROLIFERATIVE

DIABETIC RETINOPATHY

PROLIFERATIVE

NO PROLIFERATIVE LIGHT NO PROLIFERATIVE

NO PROLIFERATIVE

Diabetic Neuropathy

DISTAL AND SYMMETRIC PERIPHERAL NEUROPATHY

Symptoms

• Asymptomatic

• Numbness

• Paresthesias

• Hyperesthesia

• Pain

Signs

• ↓ Sensitivity

• Weakness

• Atrophy

Mononeuropathy

NERVIO FEMORAL AMIOTROFIA

PARES CRANEANOS

Autonomic Neuropathy

Diabetic Foot

• In patients with peripheral neuropathyincidence annual foot injuries is 7.2%.

• The etiology, 60% of injuries are neuropathic,30% are neuro-ischemic and ischemic 10%.

• Injuries are related to patient age, theglycemic control and age of the disease.

Diabetic FootDiabetic Foot

Ulceration in the foot.

Micro trauma

Developing new lines of force

Change in foot pressure areas

Peripheral neuropathy

Loss of sensation Muscle atrophy

Diabetic Foot

Diabetic Foot

• Risk Factors– Decrease or abolition of aquiliano reflex. – Decrease or abolition of vibratory sensation. – Orthopedic disorders:

• Hammer toes. • Hallux valgus. • Calluses • Atrophy of foot muscles themselves. • Pes cavus with deformed anterior arch.

– Decrease or abolition of tibial and dorsalis pedispulses.

– History of previous ulcer.

Clinical Examinatios

• Coloration: – Rubicund in neuropathy, venous engorgement. – Pale in ischemia.

• Temperature: – Hot in neuropathy. – Cold in ischemia.

• Skin alterations– Dry skin. – Presence of calluses.

• Others– Limitation of joint mobility. – Atrophy of intrinsic foot muscles.– Examination of reflexes, pulse, vibration sensitivity.

References

• Diagnosis and Classification of Diabetes Mellitus.American Diabetes Association. Diabetes Care, Volume33, Supplement 1, January 2014.Care.diabetesjournals.org

• Standards of Medical Care in Diabetes. AmericanDiabetes Association. Diabetes Care, Volume 33,Supplement 2, January 2014. Care.diabetesjournals.org

• Foot Care. Canadian Diabetes Association ClinicalPractice Guidelines Expert Committee Keith BoweringMD, FRCPC, FACP John M. Embil MD, FRCPC, FACP.March 2014.

Instrumentation

• Fingerboard 128 mHz

• Semmens Weinstein monofilament 10 g

• Radiographs of both feet with support, frontand profile

• Doppler

• Arteriography prior to surgery

Thank you for your attention