3.Diabetic Neuropathy Final

7/30/2019 3.Diabetic Neuropathy Final

1/57

Diabetic Neuropathy

fkk umj anwar wardy

Anwar Wardy W

Departemen Neurologi FKK-UMJ

[email protected]@yahoo.co.id
mailto:[email protected]:[email protected]:[email protected]:[email protected]


2/57

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 mandiri sampai tuntas.

anwar wardy w fkk umj


3/57

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.


4/57

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


5/57

Pathogenesis of Diabetic

Neuropathy

Metabolic factors

High blood glucose

Advanced glycation end products

Sorbitol

Abnormal blood fat levels

Ischemia

Nerve fiber repair mechanisms

fkk umj anwar wardy


6/57

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


7/57

Classification of Diabetic Neuropathy

Symmetric polyneuropathy

Autonomic neuropathy Polyradiculopathy

Mononeuropathy

fkk umj anwar wardy


8/57

Classification Of DN

(Dyck 1993)

Polyneuropathy Sensory Focal & Multifocal ..Motor


9/57

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


10/57

Distal Sensory DN

Risk factors for developing

distal DN :

Age

Duration of DMDiabetic control

Male & height (DCCT 90)


11/57

Distal Sensory DN

Complications

Diabetic Foot Neurogenic Arthropathy

Autonomic Neuropathy


12/57

Diabetic FootClinical Features

Numbness, hair loss, dry skin

Painless ulcers

Osteomyelitis, cellulitis, &

abcess Gangrene & Amputation


13/57

Diabetic Foot

Pathophysiology

Sensory loss & autonomic changes

Small vessel disease-Ischemia

Trauma (foreign body)

Infection


14/57

Neurogenic Arthropathy

Severe loss of pain sensation &

painless ulcers

Enhanced by trauma & abnormal

posture

XR : painless fractures-disorganization ofANKLES


15/57


Correlates with severity of distal

sensory DN

Associated with poor prognosis

50 % reduction of 5 yrs survival

Incraesed sudden death & silent MI


16/57

Autonomic NeuropathyClinical Manifestations

Postural hypotension:

BP drop >20 mmHg Bladder atony (Overflow

incontinence)

Gastro-intestinal paresis(Fullness & diabetic diarrhea)

Impotence


17/57


..Clinical Manifestations

Heat intolerance

Unawareness of hypoglycemia

Impaired hypoglycemia counter-

regulation


18/57

Focal & Multifocal neuropathies

Acute or Subacute onset

Predominantly Motor Spontaneous recovery

(Improve control)


19/57

Focal & Multifocal neuropathies

Cranial Neuropathies

Entrapment Neuropathies(Carpal Tunnel Syndrome)

Diabetic amyotrophy


20/57

DN Pathogenesis

Multifactorial

Metabolic Vascular

Others


21/57

DN Pathogenesis

Metabolic Hypothesis

Sorbitol accumulation

Non-enzymatic glycation Oxidative stress

Others


22/57

DN PathogenesisVascular Hypothesis

Early endoneural hypoxia

Nerve hypoxiaMetabolic changes& Microangiopathy & Ischemia


23/57

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

fkk umj anwar wardy


24/57

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


25/57

Treatment of Symmetric

Polyneuropathy

Glucose control

Pain control

Tricyclic antidepressants

Topical creams

Anticonvulsants Foot care

fkk umj anwar wardy

A i h


26/57

Autonomic neuropathy

Affects the autonomic nerves controllinginternal organs

Peripheral

Genitourinary Gastrointestinal

Cardiovascular

Is classified as clinical or subclinical based onthe presence or absence of symptoms

fkk umj anwar wardy


27/57

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

fkk umj anwar wardy


28/57

Peripheral Autonomic Dysfunction,

cont.

Treatment

Foot care/elevate feet when sitting

Eliminate aggravating drugs Reduce edema

midodrine

diuretics

Support stockings

Screen for CVD

fkk umj anwar wardy


29/57

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


30/57

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


31/57

Cardiovascular Autonomic

Neuropathy

Symptoms/Signs

Exercise intolerance

Postural hypotension

Treatment

Discontinue aggravating drugs

Change posture (make postural changes slowly,

elevate bed)

Increase plasma volume

fkk umj anwar wardy


32/57

Polyradiculopathy

Lumbar polyradiculopathy (diabetic

amyotrophy)

Thigh pain followed by muscle weakness and

atrophy

Thoracic polyradiculopathy Severe pain on one or both sides of the abdomen,

possibly in a band-like pattern

Diabetic neuropathic cachexia Polyradiculopathy + peripheral neuropathy

Associated with weight loss and depression

fkk umj anwar wardy


33/57

Polyradiculopathy, cont.

Polyradiculopathies are diagnosed by

electromyographic (EMG) studies

Treatment

Foot care

Glucose control

Pain control

fkk umj anwar wardy


34/57

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

fkk umj anwar wardy


35/57

Mononeuropathy, cont.

Cranial mononeuropathy Affects 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

fkk umj anwar wardy


36/57

Mononeuropathy, cont.

Treatment

Foot care

Glucose control

Pain control

fkk umj anwar wardy


37/57

Other Treatment Options

Aldose reductase inhibitors

ACE inhibitors

Weight control Exercise

fkk umj anwar wardy

C li i


38/57

Complications:

Short term Complications: (metabolic) Hypoglycemia

Diabetic Ketoacidosis

Non Ketotic hyperosmolar diabetic coma

Lactic acidosis

Long term Complications:(Angiopathy)

Microngiopathy - Retinopathy, Nephropathy,

Neurophathy, dermatopathy. Macroangiopathy Atherosclerosis.

Neuropathy


39/57

NeuropathySensoryMotor (myelin)

Peripheral Neuropathy

Bilateral, symmetric

Progressive, irreversible

Paraesthesia, pain, muscleatrophy

Visceral neuropathy

Cranial nerve diplopia, Bell

palsyGIT- constipation, diarrhoea

CVS orthostatic hypotension

Diabetic Microangiopathy


40/57

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


41/57

Chronic Polyneuropathy

Claw foot Dermopathy & Neuropathy


42/57

Diabetic Amyotrophy

Painful muscle wasting


43/57

Neuropathic ulcer

Etiology:

peripheral sensory

neuropathy, Trauma &deformity.

Factors:

Ischemia, callus formation,and edema.


44/57


45/57

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


46/57

RetinopathyNon Proliferative

Microaneurysms,

Dot- blot hemorrhages

Hard and soft exudates

Cotton wool infarcts

Macular edema.

Proliferative.

Neovascularization

Large hemorrhagesRetinal detachment.

Diabetic Retinopathy


47/57

Normal Retina Retinal H.ages

Neovascularization

Large hemorrhages

Retinal detachment.

Retinal detachment

Diabetic Retinopathy


48/57

Ath l i


49/57

Atherosclerosis:

Diabetic Gangrene


50/57

Diabetic Gangrene

Macrosomia = large birth weight


51/57

g g

more than 3.5kg (7.7 lb)

suspect mother with DM

Acanthosis Nigricans


52/57

Acanthosis Nigricans

Nephropathy


53/57

Nephropathy

Diabetic Nephropathy


54/57

Diabetic Nephropathy

Microangiopathy, atherosclerosis &

infections:

Diffuse or nodular diabetic

glomerulosclerosis (Kimmelstiel

Wilson Sy)

Renal arteriolosclerosis &

atherosclerosis

Necrotizing renal papillitis.

Pyelonephritis.

End stage kidney.


55/57


56/57

References

American Diabetes Association:Preventive Foot Care in Diabetes(Position Statement). Diabetes Care 27 (Suppl.1): S63-S64, 2004

Feldman, EL: Classification of diabetic neuropathy. In UpToDate.

Wellesley, MA, UpToDate, 2003

National Diabetes Information Clearinghouse.Diabetic Neuropathies:The Nerve Damage of Diabetes. Bethesda, MD: National Institute of

Diabetes and Digestive and Kidney Diseases, National Institutes of

Health (NIH), DHHS; 2002

National Diabetes Information Clearinghouse.Prevent Diabetes

Problems: Keep Your Feet and Skin Healthy. Bethesda, MD: National

Institute of Diabetes and Digestive and Kidney Diseases, National

Institutes of Health (NIH), DHHS; 2003

fkk umj anwar wardy


57/57

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

3.Diabetic Neuropathy Final

Documents

Transcript of 3.Diabetic Neuropathy Final