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Diabetic Neuropathy
fkk umj anwar wardy
Anwar Wardy W
Departemen Neurologi FKK-UMJ
anwarwardy@gmail.comanwar wardy@yahoo.co.id
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Dokter dengan Tingkat
kemampuan 4. Mampu membuat diagnosis klinik
berdasarkan pemeriksaan fisik dan
penunjang lain yang diminta oleh dokter(Lab.dan X-rays)
Dapat memutuskan dan mampu menangani
problem ini secara mandirisampai tuntas.
anwar wardy w fkk umj
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Diabetic Neuropathy About 60-70% of people with diabetes
have mild to severe forms of nervoussystem damage, including:
Impaired sensation or pain in the feet or
hands
Slowed digestion of food in the stomach
Carpal tunnel syndrome
Other nerve problems
More than 60% of nontraumatic lower-
limb amputations in the United States
occur among people with diabetes.
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Risk Factors
Glucose control Duration of diabetes
Damage to blood vessels
Mechanical injury to nerves
Autoimmune factors
Genetic susceptibility
Lifestyle factors
Smoking
Dietfkk umj anwar wardy
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Pathogenesis of Diabetic
Neuropathy
Metabolic factors
High blood glucose
Advanced glycation end products
Sorbitol
Abnormal blood fat levels
Ischemia
Nerve fiber repair mechanisms
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Diagnostic Tests
Assess symptoms - muscle weakness, musclecramps, prickling, numbness or pain, vomiting,
diarrhea, poor bladder control and sexual
dysfunction
Comprehensive foot exam Skin sensation and skin integrity
Quantitative Sensory Testing (QST)
X-ray
Nerve conduction studies
Electromyographic examination (EMG)
Ultrasoundfkk umj anwar wardy
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Classification of Diabetic Neuropathy
Symmetric polyneuropathy
Autonomic neuropathy Polyradiculopathy
Mononeuropathy
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Classification Of DN
(Dyck 1993)
Polyneuropathy Sensory Focal & Multifocal ..Motor
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Distal Sensory DN
The commonest type of DN (80%)
Symmetric & distal distribution Mainly sensory & painless:
Numbness, tingling, tightness
walking on cotton-wooletc.
Painful in 10%:
Burningachingsharp quality
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Distal Sensory DN
Risk factorsfor developing
distal DN :
Age
Duration of DMDiabetic control
Male & height (DCCT 90)
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Distal Sensory DN
Complications
Diabetic Foot Neurogenic Arthropathy
Autonomic Neuropathy
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Diabetic FootClinical Features
Numbness, hair loss, dry skin
Painless ulcers
Osteomyelitis, cellulitis, &
abcess Gangrene & Amputation
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Diabetic Foot
Pathophysiology
Sensory loss & autonomic changes
Small vessel disease-Ischemia
Trauma (foreign body)
Infection
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Neurogenic Arthropathy
Severe loss of pain sensation &
painless ulcers
Enhanced by trauma & abnormal
posture
XR : painless fractures-disorganization ofANKLES
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Autonomic Neuropathy
Correlates with severity of distal
sensory DN
Associated with poor prognosis
50 % reduction of 5 yrs survival
Incraesed sudden death & silent MI
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Autonomic NeuropathyClinical Manifestations
Postural hypotension:
BP drop >20 mmHg Bladder atony (Overflow
incontinence)
Gastro-intestinal paresis(Fullness & diabetic diarrhea)
Impotence
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Autonomic Neuropathy
..Clinical Manifestations
Heat intolerance
Unawareness of hypoglycemia
Impaired hypoglycemia counter-
regulation
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Focal & Multifocal neuropathies
Acute or Subacute onset
Predominantly Motor Spontaneous recovery
(Improve control)
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Focal & Multifocal neuropathies
Cranial Neuropathies
Entrapment Neuropathies(Carpal Tunnel Syndrome)
Diabetic amyotrophy
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DN Pathogenesis
Multifactorial
Metabolic Vascular
Others
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DN Pathogenesis
Metabolic Hypothesis
Sorbitol accumulation
Non-enzymatic glycation Oxidative stress
Others
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DN PathogenesisVascular Hypothesis
Early endoneural hypoxia
Nerve hypoxia Metabolic changes& Microangiopathy & Ischemia
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Symmetric Polyneuropathy
Most common form of diabetic neuropathy
Affects distal lower extremities and hands
(stocking-glove sensory loss)
Symptoms/Signs
Pain
Paresthesia/dysesthesia
Loss of vibratory sensation
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Complications of Polyneuropathy
Ulcers Charcot arthropathy
Dislocation and stress fractures
Amputation - Risk factors include:Peripheral neuropathy with loss of protective
sensation
Altered biomechanics (with neuropathy)
Evidence of increased pressure (callus)
Peripheral vascular disease
History of ulcers or amputation
Severe nail pathologyfkk umj anwar wardy
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Treatment of Symmetric
Polyneuropathy
Glucose control
Pain control
Tricyclic antidepressants
Topical creams
Anticonvulsants Foot care
fkk umj anwar wardy
A i h
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Autonomic neuropathy
Affects the autonomic nerves controllinginternal organs
Peripheral
GenitourinaryGastrointestinal
Cardiovascular
Is classified as clinical or subclinical based onthe presence or absence of symptoms
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Peripheral Autonomic Dysfunction
Contributes to the following symptoms/signs:Neuropathic arthropathy (Charcot foot)
Aching, pulsation, tightness, cramping, dry skin, pruritus,
edema, sweating abnormalities
Weakening of the bones in the foot leading to fractures
Testing Direct microelectrode recording of postglanglionic C fibers
Galvanic skin responses
Measurement of vascular responses
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Peripheral Autonomic Dysfunction,
cont.
Treatment
Foot care/elevate feet when sitting
Eliminate aggravating drugsReduce edema
midodrine
diuretics
Support stockings
Screen for CVD
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Genitourinary Autonomic
NeuropathySign/Symptom TreatmentBladder dysfunction Voluntary urination;
catheterization
Retrograde ejaculation Antihistamine
Erectile dysfunction Sildenafil, tadalafil
Dyspareunia Lubricants; estrogencreams
G i i l A i
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Gastrointestinal Autonomic
Neuropathy
Symptoms/Signs Gastroparesis resulting in anorexia, nausea, vomiting,
and early satiety
Diabetic enteropathy resulting in diarrhea and
constipation
Treatment Other causes of gastroparesis or enteropathy should
first be ruled out Gastroparesis - Small, frequent meals, metoclopramide,
erythromycin
Enteropathy - loperamide, antibiotics, stool softeners or
dietary fiberfkk umj anwar wardy
di l i
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Cardiovascular Autonomic
Neuropathy
Symptoms/Signs
Exercise intolerance
Postural hypotension
Treatment
Discontinue aggravating drugs
Change posture (make postural changes slowly,
elevate bed)
Increase plasma volume
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Polyradiculopathy
Lumbar polyradiculopathy (diabetic
amyotrophy)
Thigh pain followed by muscle weakness and
atrophy
Thoracic polyradiculopathySevere pain on one or both sides of the abdomen,
possibly in a band-like pattern
Diabetic neuropathic cachexiaPolyradiculopathy + peripheral neuropathy
Associated with weight loss and depression
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Polyradiculopathy, cont.
Polyradiculopathies are diagnosed by
electromyographic (EMG) studies
Treatment
Foot care
Glucose control
Pain control
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Mononeuropathy
Peripheral mononeuropathy
Single nerve damage due to compression or
ischemia
Occurs in wrist (carpal tunnel syndrome), elbow, or
foot (unilateral foot drop)Symptoms/Signs
numbness
edema
pain
prickling
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Mononeuropathy, cont.
Cranial mononeuropathyAffects the 12 pairs of nerves that are connected
with the brain and control sight, eye movement,
hearing, and taste
Symptoms/Signs
unilateral pain near the affected eye
paralysis of the eye muscle
double vision
Mononeuropathy multiplex
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Other Treatment Options
Aldose reductase inhibitors
ACE inhibitors
Weight control Exercise
fkk umj anwar wardy
C li i
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Complications:
Short term Complications: (metabolic)Hypoglycemia
Diabetic Ketoacidosis
Non Ketotic hyperosmolar diabetic coma
Lactic acidosis
Long term Complications:(Angiopathy)
Microngiopathy - Retinopathy, Nephropathy,
Neurophathy, dermatopathy.MacroangiopathyAtherosclerosis.
Neuropathy
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NeuropathySensoryMotor (myelin)
Peripheral Neuropathy
Bilateral, symmetric
Progressive, irreversible
Paraesthesia, pain, muscleatrophy
Visceral neuropathy
Cranial nervediplopia, Bell
palsyGIT- constipation, diarrhoea
CVSorthostatic hypotension
Diabetic Microangiopathy
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Diabetic Microangiopathy
Normal
Diabetic
Glucose
Glycosylation
BM damage leak
AGE deposition
AGE = advanced glication
end products
Narrow lumen
Ischemic Organ damage...
Ch i P l th
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Chronic Polyneuropathy
Claw footDermopathy & Neuropathy
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Diabetic Amyotrophy
Painful muscle wasting
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Neuropathic ulcer
Etiology:
peripheral sensory
neuropathy, Trauma &deformity.
Factors:
Ischemia, callus formation,and edema.
N thi l
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Neuropathic ulcers
FEATURES:Painless, surrounded by callus
At pressure points.
associated with good foot pulses
May not be associated with gangrene
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Essentials of Foot Care
Examination
Annually for all patients
Patients with neuropathy - visual inspection of feet at
every visit with a health care professional
Advise patients to:Use lotion to prevent dryness and cracking
File calluses with a pumice stone
Cut toenails weekly or as needed
Always wear socks and well-fitting shoes
Notify their health care provider immediately if any foot
problems occurfkk umj anwar wardy
Retinopathy
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RetinopathyNon Proliferative
Microaneurysms,
Dot- blot hemorrhages
Hard and soft exudates
Cotton woolinfarcts
Macular edema.
Proliferative.
Neovascularization
Large hemorrhagesRetinal detachment.
Diabetic Retinopathy
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Normal Retina Retinal H.ages
Neovascularization
Large hemorrhages
Retinal detachment.
Retinal detachment
DiabeticRetinopathy
Cataract
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Cataract
Ath l i
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Atherosclerosis:
Diabetic Gangrene
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Diabetic Gangrene
Macrosomia = large birth weight
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g g
more than 3.5kg (7.7 lb)
suspect mother with DM
Acanthosis Nigricans
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Acanthosis Nigricans
Nephropathy
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Nephropathy
Diabetic Nephropathy
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Diabetic Nephropathy
Microangiopathy, atherosclerosis &
infections:
Diffuse or nodular diabetic
glomerulosclerosis (Kimmelstiel
Wilson Sy)
Renal arteriolosclerosis &
atherosclerosis
Necrotizing renal papillitis.
Pyelonephritis.
End stage kidney.
Infections in Diabetes:
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Infections in Diabetes:
Decreased metabolismlow immunity.
Decreased function of lymphocytes & neutrophils
glycosylation/ glycation.
Glycosylation of immune mediators. Ab ( glycation of
proteins)
Capillary thickeningimpaired inflammation.
Ischemia & infarctions.
Increased glucose (alone is not the cause*)
DiabetesState of immunosuppression.
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References, cont.
Feldman, EL: Pathogenesis and prevention of diabetic
polyneuropathy. In UpToDate.Wellesley, MA, UpToDate, 2003.
Feldman, EL, McCulloch, DK: Treatment of diabetic neuropathy. In
UpToDate.Wellesley, MA, UpToDate, 2003.
Stevens, MJ: Diabetic autonomic neuropathy. In UpToDate.
Wellesley, MA, UpToDate, 2003.
Feldman, EL: Clinical manifestations and diagnosis of diabetic
polyneuropathy. In UpToDate.Wellesley, MA, UpToDate, 2003.
fkk j d