Disorders of the Pancreas Flashcards by Katie Keller

What condition is described below?

25% of this general non-obese nondiabetic population have insulin
resistance of a magnitude similar to that seen in type 2 diabetes

Insulin Resistance Syndrome

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These insulin resistant non-diabetic individuals are at much higher
risk for developing what than insulin-sensitive subjects?

type 2 diabetes

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Patients with insulin resistance syndrome are at higher risk for what other comorbidities?

Elevated triglycerides
Decreased HDLs
Hypertension
atherosclerosis
increased cerebrovascular and cardiac morbidity and mortality

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What is the leading cause of kidney failure, non-traumatic lower
limb amputations, and new cases of blindness amount adults in the
United States?

Diabetes

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What is a major cause of heart disease and stroke?

Diabetes

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What is the seventh leading cause of death in the United States?

Diabetes

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List some of the high risk populations for the development of diabetes

African Americans
Hispanics/Latinos
American Indians
Alaska Natives
Pacific Islanders

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Which type of diabetes is 5-10% of diagnosed cases of diabetes?

Type I

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Which type of diabetes is 90-95% diagnosed cases of diabetes?

Type II

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Gestational diabetes accounts for what percentage of all U.S. pregnancies?

Gestational: 7% of all U.S. pregnancies

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Normally, postprandial hyperglycemia is regulated by what?

Clearance of ingested glucose by the liver
Suppression of hepatic glucose production
Peripheral clearance of glucose

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In impaired glucose tolerance or diabetes, glucose regulation is
impaired by what?

Delayed and reduced insulin secretion
Lack of suppression of glucagon
Hepatic and peripheral insulin resistance

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Condition in which individuals have blood glucose or A1C levels
higher than normal but not high enough to be classified as diabetes

Increased risk of developing type 2 diabetes, heart disease, and
stroke

Pre-Diabetes

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Prediabetes who do what can prevent or delay type 2 diabetes and in some cases return their blood glucose levels to normal?

lose weight and increase their physical activity

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Measures of Hyperglycemia:

Reflects mean glucose over 2-3 month period

Hemoglobin A1c

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Measures of Hyperglycemia:

Without regard to time of last meal

Random plasma glucose

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Measures of Hyperglycemia:

Before breakfast

Fasting plasma glucose

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Measures of Hyperglycemia:

Post-prandial plasma glucose

2 hours after a meal

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Mainly a characteristic of insulin resistance syndrome

Features are: High serum triglyceride level: 300-400 mg/dL, Low HDL: <30mg/dL, Small dense LDL that carries supernormal quantities of cholesterol

Treatment consists of diet, exercise, and hypoglycemic control

Diabetic Dyslipidemia

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In type 2 patients, successful what remains the key to achieving control of hyperglycemia, hypertension, and dyslipidemia?

successful weight management

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Occurs predominately in adults, but becoming more common in
children and adolescents

90% of all diabetes

There is a deficiency in the response of pancreatic β cells to glucose

Genetic and environmental factors

Diabetes Type II

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What is the most important environmental factor in diabetes type II?

Obesity

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What is the pathophysiology of diabetes type II?

Less insulin production and resistance to open the gate (Circulating insulin is enough to prevent ketoacidosis but not to prevent hyperglycemia)

Beta cell dysfunction/loss

Insulin resistance

Hepatic sensitivity to insulin is decreased

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List some risk factors for diabetes type II

Older age
Overweight (BMI ≥25 or >20% over ideal body weight)
Hypertension
Abnormal lipid levels (HLD <35, TG >250)
Family history of diabetes
History of gestational diabetes
History of vascular disease
Signs of insulin resistance
PCOS
Previous IGT or IFG (impaired)
Inactive lifestyle
Race (African Americans, Native Americans, Hispanics, Pacific Islanders)

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List the essentials of diagnosis for diabetes type II

Polyuria Polydipsia Ketonuria and weight loss generally are uncommon at time of diagnosis Plasma glucose of ≥126mg/dL after an overnight fast on more than one occasion After 75g oral glucose, diagnostic values are ≥200mg/dL 2 hours after the oral glucose

What may be the initial manifestation of diabetes type II in women?

Candida vaginitis

Visceral obesity, due to accumulation of fat in the omental and mesenteric regions, correlated with what?

insulin resistance

What A1c value is diagnostic of diabetes type II?

>6.5 diagnostic for diabetes

What class of medication(s) is described below that treats diabetes type II: Work by stimulating the pancreas to secrete more insulin May cause weight gain Generally contraindicated in patients with hepatic or renal impairment Rapidly absorbed from the intestine and is metabolized in the liver, giving it a short plasma half life which causes a brief but rapid pulse of insulin

Sulfonylureas

What class of medication(s) is described below that treats diabetes type II: Decreases both the FBG and postprandial hyperglycemia in type 2 diabetics but has not effect on FBG in normal patients It is not bound to plasma proteins or metabolized but is excreted unchanged by the kidneys (Make sure kidneys are functioning well) Improves hypertriglyceridemia in obese diabetes without the weight gain associated with insulin or sulfonylurea therapy

Biguanides (Metformin (Glucophage))

What class of medication(s) is described below that treats diabetes type II: Sensitize peripheral tissues to insulin and potentiate insulin action on muscle and adipose tissue Liver function tests should be performed every 2 months for the first year and periodically thereafter

Thiazolidinediones

In diabetes type II, what is the first line drug if kidneys are normal?

Biguanides (Metformin (Glucophage))

What class of medication(s) is described below that treats diabetes type II: Oral glucose intake causes a release of gut hormones like GLP-1 (glucagon like peptide) that amplify the glucose induced insulin release Suppresses glucagon secretion

GLP-1 Receptor Agonists DPP4 Inhibitors

What is the A1c goal in diabetics?

A1c <7%

What medication is preferred second-line medication for patients with A1c >8.5 or with symptoms of hyperglycemia despite metformin titration?

Insulin

Which medication can be considered initial therapy for all patients with type 2 diabetes, particularly patients presenting with A1c >10, FPG >250, random glucose consistently >300, or ketonuria?

Insulin

Which type of diabetes is described below? 25-30% are type II (Less symptomatic than type I) African, Asian, Hispanic patients higher risk (genetic component) Look for signs: obesity, acanthosis nigricans Causes: increased childhood obesity Treatment: Lifestyle modifications with family involvement – diet and exercise, Metformin

Maturity-Onset Diabetes of Youth (MODY)

What are some macrovascular complications of diabetes type II?

Coronary heart disease Cerebrovascular disease Peripheral arterial disease

What are some microvascular complications of diabetes type II?

Retinopathy Nephropathy Neuropathy

Which type of diabetes is described below? 95% immune-mediated (Type 1a) <5% idiopathic (Type 1b) Pancreatic B cell destruction 🡪 variable Ketosis occurs when untreated- Show up in ER with DKA Most common in juveniles – can occur at any age

Diabetes Type I

What is the pathophysiology of diabetes type I?

Severe defect in insulin production Beta cell destruction = complete lack of insulin Results from damage to the insulin-producing beta cells of the pancreatic islets 🡪 damage occurs over months to years and symptoms do not appear until about 90% of cells are destroyed

What are the essentials of diagnosis for diabetes type I?

Polyuria, polydipsia, and weight loss associated with random plasma glucose ≥200mg/dL (Wont see weight loss with type 2) Plasma glucose of ≥126 mg/dL after an overnight fast, documented on more than one occasion Ketonemia, ketonuria, or both Islet autoantibodies are frequently present

What is the treatment for diabetes type I?

Insulin ONLY! No oral agents

What is the most common pediatric endocrine disease?

Type I DM

What is the second most common chronic illness?

Type I DM

Serious complication of diabetes Can be a presentation of diabetes type 1 or type 2 noncompliance

Diabetic Ketoacidosis (DKA)

What are some risk factors for DKA?

Infection – 30% Lapse in insulin administration Recent onset diabetes Medical illnesses Trauma, alcohol, steroid use idiopathic

What percentage of Type I DM children will have at least one episode of DKA?

50-60% of children

What is the pathophysiology of DKA?

DKA happens when the body is unable to produce enough insulin so the body is unable to use glucose for fuel, so it breaks down fat as alternative fuel source Leads to a rise in ketones (toxic acid) that builds faster than usage or excretion (Fat 🡪 free fatty acids 🡪 ketones) Spirals down until the patient is acidotic (metabolic acidosis) and severely dehydrated

The most numerous ketone in DKA is what?

acetoacetate

What are some early symptoms of DKA?

Nausea/vomiting Polyuria Dehydration tachycardia 1-2 day prodrome of hyperglycemia symptoms Fruity breath/acetone breath

What are some late symptoms of DKA?

Kussmaul’s breathing Abdominal pain/rigidity Altered mental status/lethargy/coma Severe dehydration

What are the key labs in working up DKA?

Urinalysis: Ketonuria, Glycosuria, Look for presence of UTI – may have set off DKA Serum glucose Serum pH Serum bicarb Serum acetone Serum potassium

What are the essentials of diagnosis for DKA?

Hyperglycemia >250mg/dL Acidosis with blood pH <7.3 Serum bicarbonate <15 meq/L Serum positive for ketones

What is the first treatment that needs to be given in DKA patients?

FLUIDS (either NS or ½ NS)

What is the treatment for DKA?

FLUIDS (Restore circulating plasma volume – first and most important!) Insulin infusion therapy as needed - 0.1 units/kg/hour If acidosis is refractory, consider bicarbonates Replace/monitor potassium closely Search for precipitating cause

Hypoglycemia is a glucose level of what?

Glucose <55

List some common causes of hypoglycemia

Tight glucose control Too much insulin Too little food Too much activity Alcohol Oral hypoglycemic agents Other medications Menstrual cycle gastroparesis

List some neurogenic symptoms of hypoglycemia

Hunger Diaphoresis Anxiety Tremors Tachycardia palpitations

List some neuroglycopenic symptoms of hypoglycemia

Behavior/cognitive changes Drowsiness Confusion Blurred vision Headaches Amnesia Seizures coma

Normal or high 0200-0300 glucose Circadian increase in insulin resistance and insulin requirements between 0300 and 0800 Attributed to excessive GH secretion

Dawn phenomenon (Morning Fasting Hyperglycemia)

Low 0200-0300 glucose Nocturnal hypoglycemia due to excessive insulin causes a reflex secretion of epinephrine which leads to hepatic glucose release

Somogyi (Rebound) Phenomenon

High mortality rate due to insidiousness, organ dysfunction, and delayed diagnosis Not going to be acidotic (Blood pH >7.3) Common etiologies: New diagnosis of diabetes in patients >65 years (30-40%), Infection (35-60%), Iatrogenic causes (10-15%)

Hyperosmotic Nonketotic Syndrome

What are some signs and symptoms of Hyperosmotic Nonketotic Syndrome?

Symptoms: Insidious onset of polyuria and polydipsia Reduced fluid intake Lethargy/confusion/coma Signs: Profound dehydration Lethary/coma Absence of Kussmaul respirations No acetone breath odor

List some complications of diabetes

Diabetic cataracts Diabetic retinopathy Glaucoma Diabetic nephropathy Gangrene of the feet Diabetic Neuropathy Charcot’s joint Chronic pyogenic infections Eruptive xanthomas Candida infections Necrobiosis lipoidica diabeticorum Cardiovascular disorders (MI, stroke, atherosclerosis, PVD, etc) Infections Macrovascular complications

What is the most common diabetic neuropathy type?

Distal symmetric polyneuropathy is the most common

A foot condition that affects people with diabetes who lose some of the feeling in their feet due to neuropathy and crush their own bones and joints

Charcot’s joint

Yellow-surfaced, irregularly shaped pretibial plaques

Necrobiosis lipoidica diabeticorum