Makindo Medical Notes.com

Related Subjects: |Metabolic acidosis |Type 1 DM | Type 2 DM | Diabetes in Pregnancy | HbA1c | Diabetic Ketoacidosis (DKA) Adults | Hyperglycaemic Hyperosmolar State (HHS) | Diabetic Nephropathy | Diabetic Retinopathy | Diabetic Neuropathy | Diabetic Amyotrophy | Maturity Onset Diabetes of the Young (MODY) | Diabetes: Complications

About

• May affect all organs

Aetiology

• Damage to long nerves e.g. vagus over time

Clinical

• Cardiovascular System:
• Resting Tachycardia: Abnormally high heart rate at rest, often exceeding 100 beats per minute.
• Orthostatic Hypotension: A significant drop in blood pressure upon standing, leading to dizziness, lightheadedness, or fainting.
• Silent Myocardial Ischemia: Reduced blood flow to the heart muscle without the typical chest pain (angina), increasing the risk of heart attacks without warning symptoms.
• Exercise Intolerance: Reduced ability to perform physical activities due to impaired heart rate response.
• Gastrointestinal System:
• Gastroparesis: Delayed emptying of the stomach contents into the small intestine, causing nausea, vomiting, bloating, and early satiety.
• Constipation or Diarrhea: Irregular bowel movements, which can include episodes of severe constipation or frequent diarrhea.
• Fecal Incontinence: Loss of bowel control due to the involvement of the nerves that control the rectum and anus.
• Genitourinary System:
• Bladder Dysfunction (Neurogenic Bladder): Difficulty emptying the bladder, leading to urinary retention, incontinence, or frequent urinary tract infections (UTIs).
• Erectile Dysfunction (ED): In men, DAN can lead to difficulty achieving or maintaining an erection.
• Retrograde Ejaculation: A condition where semen enters the bladder instead of exiting through the urethra during ejaculation.
• Sweat Gland Function:
• Anhidrosis: Reduced or absent sweating in certain areas of the body, leading to dry skin and difficulty regulating body temperature.
• Hyperhidrosis: Excessive sweating in other areas, particularly the upper body, compensating for the lack of sweating elsewhere.
• Pupillary Function:
• Reduced Pupil Reaction: The pupils may respond more slowly to changes in light, leading to difficulties in adjusting to bright lights or darkness.
• Night Vision Problems: Difficulty seeing in low light conditions due to impaired pupil dilation.

Differentials

• Peripheral: Alcohol
• Autonomic: Amyloid, Hereditary
• Immune mediated

Investigations

• Clinical History and Symptom Assessment: Detailed history taking to assess the presence of autonomic symptoms like dizziness, gastrointestinal disturbances, bladder issues, and sexual dysfunction.
• Cardiovascular Autonomic Tests:
• Heart Rate Variability (HRV) Tests: Measure the changes in heart rate in response to deep breathing, Valsalva maneuver, and changes in posture.
• Tilt-Table Test: Evaluates blood pressure and heart rate responses to changes in body position (lying to standing).
• 24-Hour Ambulatory Blood Pressure Monitoring: Assesses blood pressure fluctuations throughout the day and night.
• Gastrointestinal Tests:
• Gastric Emptying Study: A nuclear medicine test that measures how quickly food leaves the stomach.
• Breath Tests: Non-invasive tests to evaluate for conditions like small intestinal bacterial overgrowth (SIBO).
• Genitourinary Tests:
• Urodynamic Studies: Assess bladder function, including how well the bladder holds and releases urine.
• Penile Doppler Ultrasound: Evaluates blood flow in the penis to diagnose erectile dysfunction.
• Sweat Tests:
• Quantitative Sudomotor Axon Reflex Test (QSART): Measures the autonomic nerves that control sweating.
• Thermoregulatory Sweat Test: Evaluates the body's ability to sweat in response to increased temperature.

Management

• Glycemic Control:
• Tight Blood Glucose Management: Maintaining blood sugar levels within target ranges can help slow the progression of DAN and may alleviate some symptoms.
• Cardiovascular Management:
• Medications for Orthostatic Hypotension: Midodrine, fludrocortisone, or other medications can help manage low blood pressure upon standing.
• Beta-Blockers: May be used to manage resting tachycardia.
• Gastrointestinal Management:
• Prokinetic Agents: Medications like metoclopramide or domperidone can help improve gastric emptying in gastroparesis.
• Dietary Modifications: Eating smaller, more frequent meals and avoiding high-fat foods can reduce symptoms of gastroparesis.
• Genitourinary Management:
• Bladder Training and Intermittent Catheterization: For managing neurogenic bladder.
• Phosphodiesterase Inhibitors: Medications like sildenafil (Viagra) for erectile dysfunction.
• Sweat Gland and Pupillary Function:
• Topical Treatments: Moisturizers for dry skin, antiperspirants for hyperhidrosis.
• Eye Care: Artificial tears for dry eyes and sunglasses for light sensitivity.

References