Screening for diabetes and prediabetes.

Diabetes is a  chronic disease that will lead to complication in multiple organs in the body on long term especially if poorly controlled. Global increase in diabetes is due to population ageing, sedentary life style, obesity and  altered dietary habits.

Type 2 diabetes remain undiagnosed until the complication develops. One third of people living with diabetes is undiagnosed. Sceening program will help in detecting early recognition of diabetes. All those people who are at high risk for developing diabetes should be screened.

Criteria for screening asymptomatic people.

(a) Individual at 45 years and above  particularly if BMI more than  25kg/m2. If normal it should be repeated at 3 yearly interval.

(b) Testing should be done in younger age  especially if they have risk factors.

1. Physically inactive.

2. First degree relatives with diabetes mellitus.

3. Members of high risk ethnic group such as African Americans, Native American, Lation, Asian American, Pacific Islander.

4. Females with history of gestational diabetes or delivered a baby more than 9 lb.

5. Females with polycystic ovarian syndrome.

6. Hypertensive  people with BP more than 140/90 mm of Hg.

7. Those with Triglyceride more than 250mg/dl or HDL cholesterol less than 35 mg/dl.

8. Previous test showed impaired glucose tolerance or fasting glucose.

9. People with  other clinical features of insulin resistance  eg. Acanthosis Nigricans.

10. People with heart disease.

Screening test

To detect future diabetes the following test are used

Fasting glucose test(FBS)

Oral glucose tolerance test ( 2 hours after taking  75gm of glucose blood test is done).

The cumulative incidence of diabetes over 5-6 yrs based on above test Normal FBS, normal oral glucose tolerance - low risk 4 - 5%.

Impaired FBS, normal oral glucose tolerance - intermediate risk 20-34%.

Normal   FBS, Impaired oral glucose tolerance - intermediate risk 20-34%.

Impaired FBS, Impaired oral glucose tolerance - 38-65%.

Blood glucose level 2 hours after food intake (postprandial blood sugar )is directly related to the mortality and morbidity in heart disease, so 2 hour oral glucose tolerance test is done as screening procedure in people with heart disease.

Fasting glucose test is more convenient to people, more reproducible and cost effective hence ADA recommend fasting blood glucose test as the screening test.

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Gastrointestinal toxicity of NSAIDs

NSAIDs are commonly used analgesic in clinical practise. Most commonly used NSAIDS  are aspirin, diclofenac, ibuprofen, indomethacin etc. Among these aspirin is well known to cause stomach mucosal injury. After 90 minutes taking about 300-600 mg of Aspirin almost everyone will develop minute mucosal bleeding and erosion. They are associated  with various gastro intestinal side effects such as non-ulcer dyspepsia and ulcers.

Gastro intestinal side effect of NSAIDs are given below.

Dyspepsia

Oesophagitis

Oesophageal strictures

Gastric and duodenal petechiae, erosions.

Ulceration, bleeding, and perforation.

Type C gastritis

Small and large bowel ulceration, bleeding, and perforation

Exacerbation of colitis

Diagram showing mucosal erosion.area with light colour is the normal part of mucosa and reddish part represent mucosal injury

Who is at risk for gastro intestinal side effect?

Factors related to Patient.

Age more than  60 years - Elderly are prone to toxicity because of increased prevalence of ulcer disease, they are more likely to receive NSAIDS and increased sensitivity to them.

Patients with history of ulcer disease even if not related to NSAID  are also at high risk.

Drug related factors

Relatively toxic NSAID use ibuprofen at a dose  less than <1200 mg/day is associated with a lower risk compared to other NSAIDs Azapropazone and piroxicam have higher risk. As the dose of the drug increases the side effect also increases.

High dose of NSAID (or two NSAIDs used simultaneosly)

Used with anticoagulant

Concurrent use of corticosteroid

Uncertain or possible risk factors

Prolonged duration of NSAID treatment

Female sex

Those with  rheumatic disease

Heart disease

Helicobacter pylori infection

Smoking

Alcohol consumption

Management of people on NSAIDS to reduce the side effect

NSAIDS  are better avoided in those at high risk of ulceration ,if not possible they should be given prophylactic treatment.

Available drugs to treat ulcers

Patients  while on NSAIDS develop ulceration due to two reasons .Due to inhibition of prostaglandin synthesis and impairement of mucosal defence.and the acid attack will lead to frank  ulceration. Misoprostol is an analogue of prostaglandin E1. Several studies show that it prevents acute gastric injury by a wide variety of agents including NSAIDs. 400-800g daily will help to protect against NSAID  induced mucosal injury and ulceration that will help to reduce the hospitalization Side effects are diarrhoea, abdominal cramps, and reflux

Acid suppressoin - High doses of H2 antagonists and proton pump inhibitor are used.

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Clinical Features of polycythaemia

Polycythemia is a condition in which there is elevation of hemoglobin in the blood more than the normal. When hemoglobin level raise that increases the blood viscocity and lead to variety of manifestation. As it take time to increase the hemoglobin level the symptoms are also insidious. Level of hemoglobin at which each patient develop symptom vary, depending on bodies ability to adapt to the situation. Initially symptoms are mild but as the Hb is more than 20 g/d Llife threatening complication can occur.

General appearance

Increased hemoglobin and blood level causes noticeable A diffuse dusky redness of face which is called facial plethora, with bloodshot eyes  and diffuse purplish redness of oral mucosa and,palms

Conjuctival injection can occur.

Severe itching after hot bath or when the patient is warm is a feature of polycythemia which is called aquagenic pruritus.

Gout due to increased uric acid level is common.

Some patients experience stomach ulceration and heartburn.Severe malaise and fatigue are also reported.

Neurologic symptoms

Due to increased blood viscosity patients experience vertigo, tinnitus, headache, visual disturbances,mental clouding and TIA  (transient ischemic attack)

Hypertension is also common in these patients.

Arterial and venous occlusion

Life threatening complication can occur when the hemoglobin is more than   20 g/dL.At this level hyperviscocity is markedly increased and blood flow to vital organ decreases.The most common organs affected are brain ,heart, abdomen liver .Manifestation include stroke ,heart attack,hepatic vein occlusion,ischemia to the digits.

Bleeding manifestation.

Patients can develop life threatening hemorrhage. This is due to hyperviscosity leading to rupure of vessels. Unteated polycythemia patients are at risk of increased bleeding during surgery or trauma.Other bleeding manifestation include  easy bruising,epistaxis ,gastrointestinal hemorrhage.On examination spleenomegaly is common in Primary polycythemia patients.

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What is Dyspepsia or indigestion ? What are its causes?

A common complaint in clinical practice. Term dyspepsia indicate, pain or discomfort in the upper abdomen which can be acute ,chronic or recurrent. Patients with dyspepsia also complain of heartburn, that if present indicate underlying gastroesophageal reflux disease. Patients usually use the term indigestion to describe any problems related to food. It seen in 80% of population.

Characteristic associated symptoms are population.

• Upper abdominal fullness,

• Early satiety

• Burning,

• Bloating,

• Belching,

• Nausea,

• Retching,

Alarm features in dyspepsia.

• Weight loss

• Anaemia

• Persistent Vomiting

• Vomiting of blood  ,passage of blood in stool

• Difficulty in swallowing

• Palpable abdominal mass

• Constant or severe pain

If any of the alarming symptoms are present detailed evaluation is required. Detailed evaluation is also needed in people presenting with new onset dyspepsia at the age more than 55 and young people if not responding to treatment.

Causes of indigestion or dyspepsia

Indigestion directly related to food Drug Intolerance.

Sudden self limited indigestion can occur with overeating ,quick eating ,high fat food intake, eating during stressful circumstances, excessive alcohol or coffee intake.

Drug Intolerance - Commn drugs ivolved are aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, digoxin, iron, antibiotics (metronidazole, macrolides), diabetes drugs (metformin, alpha-glucosidase inhibitors, , donepezil, rivastigmine, and opioids

Gut  Dysfunction

Peptic ulcer disease (5–15% ). Gastroesophageal reflux disease ( 20% ). Gastric cancer ( 1% ). Helicobacter pylori Infection.are seen

Other Conditions

Diabetes, thyroid disease, kidney disease, heart attack, pregnancy, intra-abdominal cancers, Pancreatic Disease, Disease of the gall bladder and bile duct may be seen.

Functional Dyspepsia

Most common cause of chronic indigestion is functional dyspepsia. Upto two third of patients have no significant cause for their indigestion. Tt is difficult to treat although it is benign.

Recent employment changes, physical and sexual abuse, marital disharmony, depression, anxiety, depression, and fear of serious disease all may lead to development of symptoms. Functional dyspepsia is often seen in young people anxiety and depression or on psychiatric drugs .

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Management of dyspepsia or indigestion

Although dyspepsia or indigestion is common in general population detailed evalution is required in new onset dyspepsia in elderly people, young people not improving with empirical treatment . Also when alarming symptoms such as  weight loss, organomegaly, abdominal mass, or fecal occult blood are present.

Initial laboratory test should include

• Complete blood count,

• Electrolytes,such as serum sodium and potassium

• Liver enzymes,

• Calcium,

• Thyroid function tests.

Special Examinations

• Upper Endoscopy - Useful in detecting mucosal erosion, stomach ulceration and cancers. Young people test for H pylori is done noninvasive test for H pylori such as IgG serology, fecal antigen test, or urea breath test

• Abdominal imaging (ultrasonography or CT scanning), if disease of pancreas or gall bladder is suspected

Treatment of Dyspepsia

Functional Dyspepsia

Even though functional dyspepsia is benign and no organic cause is found it is difficult to control their symptoms

• General Measures

In those with mild and intermittent symptoms life style changes and reassurance will help to reduce the symptoms. In certain people it is precipitated by food and drugs. People should take precaution to avoid such food and drugs. Excessive alcohol, caffeine, fatty food should be avoided.

• Drugs

People with indigestion and heartburn get relief with H2-receptor antagonists examples ranitidine or nizatidine, famotidine, or cimetidine or proton pump inhibitors omeprazole, esomeprazole, or rabeprazole, lansoprazole or antoprazole.

Low doses of antidepressants such as desipramine is helpful in some patients

Metoclopromide may be tried, but chronic use is not advised

Anti-H pylori Treatment - A ntibiotic to treat H Pylori is given.

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Bariatric surgery for Obesity

Bariatric surgery is the surgical method of weight reduction. Following are the facts that should be known.
Justification - Difficulty of the condition should be greater than that of the surgery.
Aim - Is not  cosmetic, but reduce the complications of  obesity.
Surgery provides effective long lasting weight loss in morbidly obese patients.
Obesity surgery is of low priority and of doubtful value.
Obesity is the fault of the patient. Ignorance surrounding this prejudice is astounding.

Efficacy of surgery
• Involves description of weight loss following the procedures
• Target weight loss: 50% of excess weight
• The good effects noted are
     Reduction of various metabolic parameters
     Long term control of diabetes
     Loss of Lt ventricular mass
     Improvement of functioning of heart.
Selecting for surgery
• Multidisciplinary team will select suitable patient for surgery.
• Pre operative  briefing of situation is given
• BMI should be  >> 40Kg/m2        
• BMI >>35 with risk factors  
• Age between   18-55 years        
• Minimum duration of 5 years of obesity    
• Failed conservative treatment  
• No alcoholism/ Psychosis
• Those who agree for life long follow-up
Bariatric surgery procedures
Those that produce malabsorption that produce reduction of food intake.
• Jejuno ileal bypass
• Bpd
• Gastric bypass
• Vbg

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