21 August 2004

--- A Reader's Request Post

Recently, a new reader and a new blogger --- BongK --- requested that I post something on diabetes and hemorrhagic gastritis. I was quite amazed why a reader on his first visit would request on very specific topic conditions. When I visited his weblog, I found out that he has been absent from work for almost a week because her mother was hospitalized and the said conditions were part of the diagnosis. So, this post is my answer to that request. I hope other diabetic readers and those with relatives with diabetes will get enlightened too.

When DIABETES is mentioned, what is the first thing that comes to mind?

Ask the Filipino passerby and he will tell you it has something to do with blood sugar, eating sweets, "nilalanggam na ihi" (ant-attracting urine), cataracts, and probably an amputated limb or a wound that will not heal. All of these answers are correct and indeed, this goes to show us that the Filipinos' familiarity with the condition need not come from attending medical conventions but maybe because a relative or someone they know is diabetic, and they have noted the said observations.

Basically, diabetes is a disease wherein the body does not produce or properly use insulin. As you all probably know by now, the hormone insulin is necessary to convert sugar, starches and other food (carbohydrates) into energy needed for daily life.

Tito Rolly, who is also a diabetic, asked me before what is the difference between Type 1 and Type 2 diabetes, since he knows that he is a Type 2 diabetic but his doctor forgot to tell him why. For starters, there are 4 major types of diabetes:
  • Type 1 Diabetes
  • - the body fails to produce insulin.
  • Type 2 Diabetes
  • - a condition wherein the body produces insulin but is insufficient and cannot use it properly; we doctors term it as insulin resistance. Most Filipinos have this type of diabetes.
  • Gestational Diabetes
  • - affects pregnant women.
  • Pre-Diabetic
  • - occurs when a person's blood glucose levels are higher than normal but not high enough for a diagnosis of type 2 diabetes.
The most common symptoms of diabetes that necessitate you to see an endocrinologist or a diabetologist are the following:
  • excessive thirst

  • extreme hunger

  • frequent urination

  • unusual weight loss

  • easy fatigability

  • irritability

  • blurring of vision

  • wound that does not heal
Currently, there are 6-7 million Filipinos with diabetes (most are type 2), or at risk of the disease (pre-diabetics), with as many who still do not know they have diabetes. Worldwide, there are about 189 million diabetics. The numbers are increasing everyday.

Diabetic ketoacidosis (DKA) and a hyperosmolar hyperglycemic state (HHS) are two of most serious acute metabolic complications of diabetes, even if managed properly by a physician.

Please do not be afraid of the terms. I thought of trying to simplify it, but there is no other way, people --- you simply got to know the real stuff. But don't worry, I'll try to be as gentle as possible.

DKA and HHS can occur in both type 1 and type 2 diabetes. The mortality rate in patients with DKA is less than 5 percent in experienced hospital centers (those that handle numerous cases), whereas the mortality rate of patients with HHS still remains high at ~15 percent. The picture gets ugly for both conditions when the patients are at the extremes of age and in the presence of coma and hypotension (low blood pressure).

The BASIC reason for the DKA and HHS is a reduction in the net effective action of circulating insulin coupled with a concomitant elevation of counterregulatory hormones, like glucagon, catecholamines, cortisol, and growth hormone. These counterregulatory hormones, in turn, lead to increased liver and kidney glucose production and impaired glucose utilization in peripheral tissues, which result in increased blood sugar (hyperglycemia).

Now, here comes the good parts. Pay careful attention to the following diagrams:


insulin deficiency + increased counterregulatory hormones ---->
  • release of free fatty acids into the circulation from adipose tissue (lipolysis), and

  • unrestrained liver fatty acid oxidation to ketone bodies

  • resulting ketonemia and metabolic acidosis


the cause is INADEQUATE plasma insulin concentrations to facilitate glucose utilization by insulin-sensitive tissues.

In both DKA and HHS, there is glycosuria or the previously mentioned "nilalanggam na ihi," with loss of water, sodium, potassium, and other electrolytes. And when your doctor orders a laboratory blood examination from you, he will be able to differentiate if you as a diabetic, is suffering either from DKA or HHS depending on the magnitude of dehydration and degree of ketosis and acidosis produced by your body.
The most common precipitating factor in the development of DKA or HHS is INFECTION. Other precipitating factors include:
  • cerebrovascular accident
  • alcohol abuse
  • pancreatitis
  • myocardial infarction
  • trauma
  • drugs like corticosteroids, thiazides, and sympathomimetic agents (dobutamine and terbutaline)
HHS usually evolves over several days to weeks. In contrast, the evolution of the acute DKA episode in type 1 diabetes or even in type 2 diabetes tends to be much shorter.

Although the symptoms of poorly controlled diabetes may be present for several days, the metabolic alterations typical of ketoacidosis usually evolve within a short time frame usually in less than 24 hours.

As part of the "suspense of being a doctor," the entire symptomatic presentation may evolve or develop more acutely, (and this is the part where we worry) and the patient may present in DKA with no prior clues or symptoms.

For both DKA and HHS, the CLASSICAL CLINICAL PICTURE includes a history of
  • frequent urination
  • excessive thirst
  • extreme hunger
  • weight loss
  • vomiting
  • abdominal pain (only in DKA)
  • dehydration
  • weakness
  • disorientation
  • and finally COMA
Physical findings may include poor skin turgor, rapid breathing or hyperventialation (in DKA), rapid heart rate, low blood pressure, alteration in mental status, shock, and ultimately COMA, which is more frequent in HHS.

Up to 25 percent of DKA patients have vomitting, which may be coffee-ground in appearance and positive for blood on laboratory examination.

Endoscopy or the process of inserting a visualizing instrument to see the digestive tract, has related this finding to the presence of HEMORRHAGIC GASTRITIS. I still do not know if endoscopy was done on BongK's mom, but I am assuming her attending physician was exercising good medical judgment when he diagnosed her as having hemorrhagic gastritis.

Mental status can vary from full alertness to profound lethargy or COMA, with the latter more frequent in HHS.

Diabetes is a dreadful disease. It has killed most of my relatives and people I love.

Some of us, like me, like Tito Rolly, like Ting-Aling, probably BongK too, and most of you out there reading this looooong post, have been predestined to have this scourge.

While we cannot escape our fates, we can however, delay the onset of complications by strictly following a healthy code of life, striving to minimize the risks to hasten the process, and hoping we can last long enough to share happiness with our loved ones.

Do you have a diabetic risk? Take this DIABETIC RISK TEST and know where you stand. My score is 6.

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