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
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