DYSFUNCTION OF THE ENDOCRINE

PANCREAS:

Diabetes Mellitus
 Diabetes Mellitus

 is a group of metabolic diseases

characterized by hyperglycemia
resulting from defects in insulin
secretion, insulin action, or both.
Action of Insulin on the Cell Metabolism
Classification
 The American Diabetes Association (ADA)
classifies four categories of DM:

 Type 1 (beta-cell destruction, usually leading to

absolute insulin deficiency)
 Type 2 (ranging from predominantly insulin
resistance with relative insulin deficiency to
predominantly an insulin secretory defect with
insulin resistance)
 Other specific types
 Gestational diabetes
Type I Diabetes

 Low or absent endogenous insulin

 Dependent on exogenous insulin for
life
 Onset generally < 30 years
 5-10% of cases of diabetes
 Onset sudden
 Symptoms: 3 P’s: polyuria, polydypsia,
polyphagia
Type I Diabetes Cell
Clinical Manifestations
 Polydipsia
 Polyuria
 Polyphagia
 Weight loss
 Fatigue
 Type II Diabetes

 Insulin levels may be normal, elevated or

depressed
 Characterized by insulin resistance,
 diminished tissue sensitivity to insulin,
 and impaired beta cell function (delayed or
inadequate insulin release)
 Often occurs >40 years
Type II Diabetes
Type II Diabetes
 Risk factors: family history,
sedentary lifestyle, obesity and
aging
 Controlled by weight loss, oral
hypoglycemic agents and or insulin
Clinical Manifestations
 Recurrent infections (e.g., boils and
carbuncles; skin infections) and
prolonged wound healing)
 Genital pruritus
 Visual changes
 Paresthesias
 Fatigue
Diagnostic Criteria

1. HbA1c ≥6.5%
2. FPG ≥126 mg/dl (7.0 mmol/L); fasting is
defined as no caloric intake for a least 8 hr
3. 2-hr plasma glucose ≥200 mg/dl (11.1
mmol/L) during an OGTT
4. In a patient with classic symptoms of
hyperglycemic crisis, a random plasma glucose
≥200 mg/dl (11.1 mmol/L)
 
Categories of Increased Risk for Diabetes
1. FPG 100 to 125 mg/dl
2. 2-hr PG in the range of 75 to 199 mg/dl during
an OGTT
3. HbA1c5.7% to 6.4%
Management of Diabetes Mellitus

 Nutrition

 Blood glucose
 Medications

 Physical activity/exercise

 Behavior modification
 Other Specific Types of Diabetes
Mellitus

 Genetic defects of beta-cell function

 Genetic defects in insulin action
 Endocrinopathies
 Drug- or chemical-induced beta-cell
Dysfunction
 Infections
 Uncommon forms of immune-mediated
diabetes mellitus
 Other genetic syndromes sometimes
 Gestational Diabetes Mellitus
(GDM)
 Any degree of glucose intolerance with
onset or first recognition during pregnancy

 Women who are obese, older than 25 years

of age, have a family history of diabetes,
have a history of previous GDM

 The metabolic stress of pregnancy may

uncover a genetic tendency for type 2
diabetes mellitus
 Acute Complications of
Diabetes Mellitus
Diabetic Ketoacidosis (DKA)
 Results from breakdown of fat and
overproduction of ketones by the liver and
loss of bicarbonate
 Occurs when Diabetes Type 1 is undiagnosed
or known diabetic has increased energy
needs, when under physical or emotional
stress or fails to take insulin
 Mortality as high as 14%

 Pathophysiology
 Hypersomolarity (hyperglycemia, dehydration)
 Metabolic acidosis (accumulation of ketones)
 Fluid and electrolyte imbalance (from osmotic
diuresis)
Diabetic Ketoacidosis (DKA)
[cont.]
Clinical Manifestations
 Kussmals respirations
 Blow off carbon dioxide to reverse acidosis
 Fruitybreath
 Nausea/ abdominal pain

 Dehydration

 Lethargy

 Coma

 Polydipsia, polyuria, polyphagia

Diabetic Ketoacidosis (DKA)
[cont.]
Diagnostic tests

 Blood glucose greater than 250 mg/dL

 Blood pH less than 7.3
 Blood bicarbonate less than 15 mEq/L
 Ketones present in blood
 Ketones and glucose present in urine
 Electrolyte abnormalities (Na, K, Cl)
 serum osmolality < 350 mosm/kg
(normal 280-300)
 Diabetic Ketoacidosis
(DKA) [cont.]
Treatment
 Requires immediate medical attention and
usually admission to hospital
 Frequent measurement of blood glucose and

treat according to glucose levels with regular

insulin (mild ketosis, subcutaneous route;
severe ketosis with intravenous insulin
administration)
 Restore fluid balance: initially 0.9% saline at

500 – 1000 mL/hr.; regulate fluids according

to client status; when blood glucose is 250
mg/dL add dextrose to intravenous solutions
Diabetic Ketoacidosis (DKA)
[cont.]
Treatment

 Correct electrolyte imbalance: client often is

initially hyperkalemic
 Monitor cardiac rhythm since hypokalemia
puts client at risk for dysrrhythmias
 Treat underlying condition precipitating DKA
 Acidosis is corrected with fluid and insulin
therapy and rarely needs bicarb
Hypersomolar Hyperglycemic
Nonketotic Syndrome (HHNS)
 Potential complication of Diabetes Type 2
 Life threatening medical emergency
 Enough insulin is secreted to prevent
ketosis, but not enough to prevent
hyperglycemia
 High blood sugar causes an extreme
diuresis with severe electrolyte and fluid
loss
 Characterized by
 Plasma osmolarity 340 mOsm/l or greater-
normal 280-300
 Blood glucose severely elevated, 800-1000
 Altered level of consciousness
Hypersomolar Hyperglycemic
Nonketotic Syndrome (HHNS) [cont.]
Precipitating Factors

 Infection (most common)- pneumonia

 Therapeutic agent or procedure
 Acute or chronic illness
 MI
 Stroke
 Pancreatitis
 Pregnancy
 Slow onset 1 – 14 days
Hypersomolar Hyperglycemic
Nonketotic Syndrome (HHNS) [cont.]
Pathophysiology
a. Hyperglycemia leads to increased urine output
and dehydration
b. Kidneys retain glucose; glucose and sodium rise
c. Severe hyperosmolar state develops leading to
brain cell shrinkage

Manifestations
a. Altered level of consciousness (lethargy to coma)
b. Neurological deficits: hyperthermia, motor and
sensory impairment, seizures
c. Dehydration: dry skin and mucous membranes,
extreme thirst, tachycardia, polyuria,
hypotension
Hypersomolar Hyperglycemic
Nonketotic Syndrome (HHNS) [cont.]
Treatment
 Usually admitted to intensive care unit of hospital
for care since client is in life-threatening
condition: unresponsive, may be on ventilator,
has nasogastric suction
 Correct fluid and electrolyte imbalances giving
isotonic or colloid solutions and correct
potassium deficits
 Lower glucose with regular insulin until glucose
level drops to 250 mg/dL.
 Monitor for renal failure
 Treat underlying condition
Acute Complications of
Diabetes Mellitus (cont.)
 Somogyi Effect is a unique combination of
hypoglycemia followed by rebound
hyperglycemia.

 Dawn Phenomenon is an early morning

rise in blood glucose concentration with no
hypoglycemia during the night.
Chronic Complications of
Diabetes Mellitus
 Microvascular Disease
 Diabetic Retinopathy
 Diabetic Nephropathy
 Diabetic Neuropathies

 Macrovascular Disease
 Coronary Artery Disease.
 Stroke
 Peripheral Arterial Disease

 Infection