Difficult Case on T2Diabetes Management 2 Dr bounmy SOMSAMOUTH Chief of endocrinology Setthathirath Hospital

Case 2 A 34 years old Lao women. who was diagnosed as having type 2 diabetes 8 year ago. She has mild hypertension but no evidence of coronary disease or other complication of diabetes. She is managed with insulin 2 year and poor control of hyperglycemia; recent A1c from 10-12% One year ago, the Pt began having episodic nausea and vomiting. The problem increased in frequency, for the past 6 months some degree of nausea and vomiting has been present daily.

Symptoms Occur most commonly in the morning and with eating, when early satiety, bloating, and fullness also are present. Associated with dizzy, fatigue, loss of appetite, vision Loss and neck pain No fever, cough, weight loss.

Physical Examination Good mental state General condition: moderate dehydration Vital signs : Bp 120/90 mmHg, pulse 90-100 bpm, Heart: tachycardia, lungs : normal ,abdominal soft Mild edema at the face Dorsalispedis pulse: normal, loss sensory and mild numbness

What do you think? Differential Diagnosis? DKA? HHS? Chronic gastritis? PUD? CA gastric? Diabetic neuropathy(Diabetic gastro paresis)? Medication ?

Investigation CBC Electrolyte Glucose, BUN, Creatinine, cholesterole, triglyceride, liver function. Endoscopy CT abdomen

Result investigation Date .month. year Result Glycemia 123,146,130 BUN 15mg,17mg, 16mg/dl Creatinine 1.8mg,1.3mg,1,3mg/dl Cholesterole 400mg/dl Triglyceride 81mg/dl A1c 7,2% CBC HGB7.8g/dl HCT23%,PTL 299,000 U/A Protein500mg/dl,Glucose 1000mg/dl,Ery 50 Gastroscopy Normal Ultrasound Abdominal Fundus copy NPDR(non proliferative retinopathy)

Final Diagnosis? Diabetic gastro paresis ?

What is Gastroparesis? Gastroparesis means weakness of the muscles of the stomach. ແມ່ນຄວາມຜິດປົກະຕິຂອງລະບົບປະສາດ ແລະກ້າມຊີ້ນຂອງກະເພາອາຫານ. ໝາຍເຖິງການຂັບເຄື່ອນອາຫານຈາກກະເພາະຫາລຳໃສ້ຊ້າກວ່າ ປົກະຕິ ເປັນສາເຫດເຮັດໃຫ້ກະເພາະອາຫານເຕັມຕະຫຼອດ ຄວາມຜິດປົກະຕິດັ່ງກ່າວ: Gastricdysrhythmias, Antral hypomotility Incoordination of antroduodenal contractions Gastroparesis

Causes of gastroparesis • Diabetes • Surgery involving any of the digestive organs, such as the stomach and bowels • Certain medicines, such as strong pain medicines (narcotics) • Certain conditions, such as systemic scleroderma, Parkinson disease, and thyroid disease • After a viral illness

How should we know ? First, many of the people with gastroparesis have long-standing diabetes and evidence of damage to other organs Second, many of these people have other symptoms of neuropathies(mono neuropathy, peripheral neuropathy)

Symptoms of GP Nausea and vomiting up partially digested food that has been sitting in the stomach Dry heaves Abnormal bloating Abdominal pain Loss of appetite The feeling of filling up too quickly while eating

Gastroparesis Diagnosis Upper gastrointestinal x-ray, and a gastroscopy Rule out other diseases such as ulcer, gastritis and gastric cancer, pyloric stenosis ,and et … 50% of diabetics may show signs of gastroparesis Another investigation

Final Diagnosis Diabetic gastro paresis

How should we treatment? Control blood glucose level High blood glucose levels can slow stomach emptying and add to the problem. Dietary Eat small meals throughout the day rather than a few larger ones. Cut back on fatty foods, cut back on difficult to digest foods: legumes, lentil, and citrus fruits

How should we treatment? cont Medication Metoclopramide Which acts on the nervous system to increase the strength and frequency of gastrointestinal muscle contraction. It taken 20-30 minutes before mean and at bedtime Domperidone Improves stomach emptying by stimulating stomach motor activity

Management cont Other conventional antiemetic agents Neuropsychiatric Prochlorperazine, promethazine (phenergan) antispasmodics Neuropsychiatric Antidepressants Amitriptyrine Erythromycin is a commonly used antibiotic that binds to receptors in the stomach and small intestine called “motilin receptors

Surgery The most popular option is ajejunostomy tube

Gastro paresis Prognostic When a diabetic gastro paresis will get better Some people with this disease will have to be hospitalized regularly. After some months or years, the disease seems to burn itself out and the person improves

ສະຫຼຸບ ຄົນເຈັບທີ່ເປັນເບົາຫວານສົມທົບກັບອາການປວດຮາກ ແລະຮາກຄິດຫາ Diabetic gastropathy. ຄົນເຈັບເບົາຫວານຕ້ອງຄຸມນ້ຳຕານໃຫ້ຢູ່ເກນປົກະຕິເພື່ອຫຼີກລ໊ຽງການເປັນ diabetic gastroparesis ແລະອາການສົນອຶ່ນໆ ການປິ່ນປົວ diabetic gastroparesis: ຄຸມນ້ຳຕານໃຫ້ຢູ່ເກນປົກະຕິ ປະສະຈາກອາຫານມັນ,ໃຍ, ແກ່ນໝາກໃມ້ ອາຫານມິລົດສົ້ມ ແລະເທື່ອລະນ້ອຍ ການໃຫ້ຢາປິ່ນປົວອາການ ການຜ່າຕັດ

Thank you For Your attention