Complications of Diabetes - SHORT TERM COMPLICATIONS
Diabetes can affect nearly every system of the body. The complications of diabetes can be short-term like infections and diabetic ketoacidosis or long-term like blood vessel diseases. Short term complications are more likely to occur when diabetes is uncontrolled than when it is regulated and are more common in those who are careless.
Infections
A person with an uncontrolled diabetes has a diminished resistance to bacterial and fungal infections. Multiple, often atypical organisms, tissue destruction and relative absence of pain characterize these infections. Infections increase the secretion of hormones which oppose the action of insulin, increase blood glucose and if adequate insulin is not available, result in the formation of ketones. Vigorous treatment of infection and diabetes has to be carried out simultaneously.
Tuberculosis
A chest x-ray is often routinely asked in the initial examination of a diabetic and whenever diabetes is uncontrolled without any obvious cause. A diabetic should report to a doctor in case of persistent cough, weakness, loss of appetite, or fever. Formerly, the combination of diabetes and tuberculosis was dreaded. With insulin and the antituberculosis drugs, tuberculosis can now be effectively arrested in a person with diabetes. Risk of reappearance of tuberculosis is always present when diabetes is uncontrolled.
Ear and nose
Fungal infection of nose and external ear is a rare but sinister complication of diabetes, because of its tendency to penetrate adjoining structures. A diabetic should not take lightly any pain in or discharge from nose or ear, nose bleed or impaired hearing.
Gums and teeth
Painful, swollen, red and bleeding gums with pockets of pus between teeth and gums, loosening of teeth may occur in uncontrolled diabetes. The condition of gums and teeth improves with the control of diabetes. A diabetic should brush his teeth with a good tooth paste twice a day and should avoid chewing betel nut and pan. He should visit his dentist at least once a year and especially when there is a dental problem. Control of diabetes is essential before any dental procedure.
Skin
Boils are common when diabetes is uncontrolled and often diabetes is detected because of boils. Skin and the underlying tissue may become hard, warm, red and tender with pus discharging at several points. This condition, a carbuncle, occurs commonly on the back and nape of the neck. Swelling and redness around nail bed due to fungal infection is often seen in diabetics. It responds to local application of antifungal solution.
Vulva and vagina
Itching, redness and white discharge are common complaints when diabetes is uncontrolled. This is due to fungal infection. Apart from defective defence mechanism due to uncontrolled diabetes, excess of glucose encourages the growth of fungi. These complaints subside promptly when diabetes is controlled.
Male genitalia
Redness and cracks on the foreskin, inability to retract the foreskin, redness of the glans penis and discharge occur in uncircumcised males when diabetes is uncontrolled. This problem subsides when diabetes is controlled. Circumcision, that is, removal of foreskin is often not required.
Urinary tract
Urinary infections are more common in women than in men due to the anatomical features of the former. In women, the urethra may be irritated during sexual intercourse. Childbirth may weaken the floor of the pelvis that supports the urinary bladder. The changes in vaginal and the urethral lining that occur in menopause predispose to urinary infection. Abnormal function of urinary bladder due to involvement of its nerves contributes to urinary tract infection.
Urinary tract infection gives rise to burning and frequency of micturition, fever often with shivering, pain in the loins or above the pubis and vomiting.
The examination of urine shows increased number of pus cells and a small amount of protein. A culture of urine is essential to identify the offending organisms and their sensitivity to antibacterial drugs. In case of repeated urinary infection, an ultrasonography of the kidney and bladder is essential, to detect any obstruction to flow of urine, defective emptying of urinary bladder and the condition of the kidneys. Repeated urinary infection may damage the kidneys. Since diabetes itself can affect the kidney function, the importance of prompt treatment of urinary infection in a diabetic is obvious.
A woman with diabetes should be careful about the hygiene of the perineum. After passing stools, she should wipe the part, with a front to back motion. She should drink 6 to 8 glasses of water per day and should not postpone urination. 'Her underclothes should be clean and made of cotton. She should make it a point to pass urine before and after sexual intercourse.
Principles of management of diabetes and infection
A diabetic should report to his/her doctor in case of any infection. The sensation of pain is often impaired in diabetes, resulting in an underestimation of the severity of an infection.
Any infection increases the insulin requirement. A diabetic usually treated by tablets or by diet alone may need insulin temporarily during an infection. Blood glucose should be tested frequently in the presence of an infection. Urine should be tested for ketones when urine contains large amount of sugar. The dose of insulin should be increased if blood glucose has increased. In the presence of an infection, two to three daily injections of short-acting insulin are often necessary, in place of a single daily injection of a long-acting or an intermediate-acting insulin. The insulin requirement falls after the infection is controlled. An appropriate antimicrobial drug is given. Any dead tissue is removed surgically. The insulin requirement falls after pus is drained and infection is controlled.
Infections often give rise to loss of appetite, nausea, or stomach upset. For modification of diet in such circumstances, see Chapter 19.
Coma in diabetics
Coma due hypoglycaemia has already been discussed (Ch. 13). Coma can occur in marked hyperglycaemia or very high blood glucose level. Coma can occur with poor kidney function, stroke or any other disease. An urgent admission to a well equipped hospital is essential.
Diabetic ketacidosis
This is a very serious complication of diabetes. Before the discovery of insulin, this was the most common cause of death amongst diabetics. Omission of insulin in type 1 diabetes is the most important cause of diabetic ketoacidosis and coma. Any infection, like a carbuncle, abscess, pneumonia or vomiting or diarrhoea worsens diabetes and may result in diabetic coma, if not treated properly. An infection may give rise to loss of appetite, nausea or vomiting. A diabetic may not be able to have his usual diet. Often it is assumed that since the usual meal has not been taken, insulin is not necessary and hence is omitted. This mistake is disastrous since infection increases the insulin requirement.
Any stress such as an infection or a surgical operation, increases the insulin requirement. The body fat is broken down when insulin is deficient. The breakdown products of fats, called ketone bodies, accumulate in blood and later appear in urine when diabetes is severe. The ketone bodies are acidic and hence their accumulation in the body causes acidosis. Blood glucose level is high and there is a marked loss of water, sodium, potassium and bicarbonates.
Coma develops gradually. Before actual coma or unconsciousness develops, the diabetic loses appetite, gets nausea or vomiting and abdominal pain. The tongue is dry, face is flushed, breathing is deep and rapid and the pulse, rapid and feeble. The patient becomes drowsy and lapses into unconsciousness.
Urine should be tested every four hours for ketones, whenever there is lot of glucose in urine or in presence of an infection, vomiting, diarrhoea, drowsiness etc. Blood glucose should be tested immediately. The diabetic should rest and take plenty of fluids like soups, broths etc., if he has more than a trace of ketones in urine. A changeover to insulin is essential, if the person is on oral drugs. If already on long acting insulins, a changeover to short-acting insulin before main meals is advisable. A changeover to short acting, monocomponent insulin is essential if conventional insulin preparations are ineffective.
An admission to a well equipped hospital is imperative when a diabetic develops vomiting, ketosis, drowsiness or unconsciousness. The treatment of this emergency consists of continuously maintaining an optimum level of insulin in blood, prompt administration of large amount of fluid, sodium and potassium and eradication of underlying cause. Although prospect of this complication had improved in recent years, the mortality is still high in the elderly.
Hyperosmolar nonketotic hyperglycaemia
This occurs more commonly with type 2 diabetes in the middle aged and the elderly. The blood glucose level is very high and there is a marked loss of water from the body. Ketosis is absent since insulin deficiency is not as marked as in the ketotic coma.
The treatment consists of insulin and large amounts of water, sodium and potassium. Mortality is quite high.
Lactic acidosis
Coma due to accumulation of lactate in blood may occur in diabetics taking biguanides, especially phenformin (now banned in India), in the presence of impaired kidney, liver and heart function, sepsis and shock. It presents with deep and rapid breathing, vomiting and abdominal pain and is attended with considerable mortality.