Diabetic Neuropathy a2w

8/12/2019 Diabetic Neuropathy a2w

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Diabetic Neuropathy

fkk umj anwar wardy

Anwar Wardy W

Departemen Neurologi FKK-UMJ

[email protected] [email protected]
mailto:[email protected]:[email protected]:[email protected]:[email protected]


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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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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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..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

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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

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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

Diabetic Neuropathy a2w

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