Diabetesrelaterade Magtarmstörningar - patientfall

Patientfall1

This Week's Case:

A 30-year-old white male insulin-dependent diabetic presents with severe, unremitting diarrhea of one month's duration. He describes his diarrhea as loose, explosive, mainly nocturnal and associated with the passage of much gas but no blood, undigested food, or mucus. Since its onset, his diabetes control had grown more difficult with frequent hypoglycemic episodes. He also complains of dysesthesias of his lower extremities, postural dizzyness, total impotency, and frequent vomiting requiring pre-prandial cisapride therapy. His diabetes began at age 10 and, though under fair control, he has developed retinopathy requiring laser therapy and mild renal failure. His blood pressure, however, has remained normal or low and he denies any cardiovascluar symptoms. Except for imodium, prn, and insulin, he is on no other medical therapy.

Make a differential diagnosis:

Primary DX

2

3

4

Physical Exam

On physical exam, BP = 110/75 supine and 85/60 standing. Pulse = 100 and regular.
Temperature is normal. Fundoscopic exam shows grade III diabetic retinopathy with microaneursms, small hemorrhages, exudates, and laser scars. HEENT is unremarkable. Lungs and heart are normal. Abdominal exam shows no organomegaly, and except for a loose sphinctor, rectal is negative. Neurologic exam shows absent knee and ankle jerks, decreased vibration and position sense, and hypesthesia below the knees.

Modify your differential diagnosis:

Primary DX

2

3

4

Labs & Studies Request For
Please select the labs you would like to order:

Creatinine

Glycohemoglobin

WBC

Hemoglobin

Free thyroxine

Amylase

Albumin

Electrolytes

Celiac disease panel

Magnesium

Urinalysis

Cholesterol

Stool cultures

D-xylose excretion

BUN

Labs & Studies Results

Modify your differential diagnosis:

Primary DX

2

3

4

Additional Information

Chest x-ray, upper GI and small bowel series, barium enema and sigmoidoscopy are all unrevealing. However, following a three-week course of doxycycline therapy, the patient's diarrhea ceased.

Modify your differential diagnosis:

Primary DX

2

3

4

---

Diagnosis

The correct diagnosis is Diabetic diarrhea

Diabetic diarrhea is probably the worst disease that diabetic specialists and endocrinologists, in general, see. As in this patient, it is explosive, uncontrollable by the usual measures, incapacitating, and represents a major nursing problem in hospitalized or nursing home patients. It is usually associated with advanced peripheral and autonomic neuropathy and makes blood sugar control exceedingly difficult, if not impossible, to achieve.

Because of the severe prognosis it portends, as well as the many managemen problems it presents, every effort must be made to differentiate this condition from those more manageable, such as, pancreatic insufficiency, celiac disease, and infectious causes of diarrhea. Once in a lifetime, one may even encounter a gastrinoma, somatostinoma, glucagonoma, or medullary thyroid carcinoma.

Since its pathogenesis involves neurogenic bowel stasis with bacterial overgrowth, it is always worthwhile to try the patient on a prolonged course of a broad-spectrum antibiotic, such as tetracycline or ciprofloxin, and if one is lucky approximately one third of cases will respond, at least for a time. Should this treatment and other simpler measures fail, one is left with high doses of clonidine on the average of 1.2 mg per day (which, when effective, also causes a paradoxical rise in blood pressure) and intensive octreotide therapy -- or in the most extreme cases, total colectomy. Cisapride is helpful, at least for a time, in managing the gastric paresis that usually accompanies this condition. It is often also helpful to give symptomatic therapy with Imodium(loperamid) or better Primodium (loperamidoxid). The latter has more effect in the distal ileum and colon and less system absorption.

In addition, adequate nutrition, the correction of any vitamin deficiencies, and the prevention of wide swings in blood glucose levels, must all be accomplished. In short, it as a nightmare for both patient, doctor, and nursing service alike.

Learning Points:

1. In a longstanding, usually insulin-dependent diabetic, the onset of explosive, nocturnal, uncontrolled diarrhea is ominous and may represent "diabetic diarrhea."

2. Other causes of diarrhea that diabetics may be prone to, such as pancreatic insufficiency and celiac disease, must be excluded.

3. One third of cases of diabetic diarrhea will respond, if temporarily, to a prolonged course of broad-spectrum antibiotics.

---

References: Standard diabetic texts, plus
Valdovinos, M et al. Chronic Diarrhea in Diabetes Mellitus. Mayo Clinic Proc. 68:July 1993 p691-5.