1. DIABETIC NEUROPATHY PAWUT MEKAWICHAI MD DEPARTMENT OF MEDICINE MAHARAT NAKORNRAJSIMA HOSPITAL

2. About 60-70% have mild to severe forms of nervous system damage, including:  Impaired sensation or pain in the feet or hands  Slowed digestion of food in the stomach  Carpal tunnel syndrome  Orthostatic hypotension  Other nerve problems More than 60% of nontraumatic lower-limb amputations in the United States is diabetes DIABETIC NEUROPATHY

3.  Glucose control  Duration of diabetes  Damage to blood vessels  Mechanical injury to nerves  Autoimmune factors  Genetic susceptibility  Lifestyle factors- smoking, diet RISK FACTOR

4. Metabolic factors  High blood glucose  Advanced glycation end products  Sorbitol  Abnormal blood fat levels Ischemia Nerve fiber repair mechanisms PATHOGENESIS

5. Symmetric polyneuropathy  Distal sensory or sensorimotor polyneuropathy  Small fiber neuropathy  Large fiber neuropathy  Autonomic neuropathy Asymmetric polyneuropathy Combination CLASSIFICATION

6.  Most common form of diabetic neuropathy  Affects distal lower extremities and hands (“stocking-glove” sensory loss)  May be up to anterior abdominal wall  Symptoms/Signs  Pain  Paresthesia/dysesthesia  Loss of vibratory sensation DISTAL SENSORIMOTOR POLYNEUROPATHY

7. DISTAL SENSORIMOTOR POLYNEUROPATHY

8. Ulcers Charcot arthropathy at small joint (SY = knee joint) Dislocation and stress fractures Amputation - Risk factors include:  Peripheral neuropathy  Evidence of increased pressure (callus)  Peripheral vascular disease  History of ulcers or amputation  Severe nail pathology DISTAL SENSORIMOTOR POLYNEUROPATHY COMPLICATION

9. DISTAL SENSORIMOTOR POLYNEUROPATHY

10.  Pure autonomic neuropathy  Range from subclinical impairment of CVS reflex and sudomotor function to severe CVS/GI/GU dysfunction Sudomotor : distal anhydrosis with compensated facE and truncal sweating heat intolerance, gustatory sweating Slow reactive pupil AUTONOMIC NEUROPATHY

11. CVS : orthostatic hypotension GI : delay gastric emptying time = early satiety, bloating diabetic diarrhea (night diarrhea, explosive, paroxysmal, no weight loss or malnutrition) bacterial overgrowth colonic atrophy = constipation GU : retention or incontinence, impotence AUTONOMIC NEUROPATHY

12. Orthostatic hypotension up head position drinking before bedtime elastic body stocking plasma volume expansion : fludrocortisone  -agonist : midodrine Treatment ANS dysfunction AUTONOMIC NEUROPATHY

13. Delay gastric emptying time : metropropamide Diabetic diarrhea and bacterial overgrowth : short course of tetracycline or erythromycin Neuropathic bladder : voiding schedual, abdominal compression Erectile dysfunction : urologic procedure sildenafil (viagra) Treatment ANS dysfunction AUTONOMIC NEUROPATHY

14. Small fiber neuropathy  small fiber (A  and C fiber)  burning feet or painful neuropathy Large fiber neuropathy (diabetic pseudotabes )  Rare, painless ataxic sensory polyneuropathy  Loss of vibration and proprioceptive sense AUTONOMIC NEUROPATHY

15. Symmetric polyneuropathy Asymmetric polyneuropathy  Thorasic radiculopathy  Lumbrosacral radiculopathy  Mononeuropathy Combination CLASSIFICATION

16. Thorasic radiculopathy  rapid onset of pain and paresthesia at chest wall  touch sensitive  DDx with MI, disc disease ASYMMETRIC NEUROPATHY

17. Lumbrosacral radiculopathy (diabetic amyotrophy diabetic femoral neuropathy diabetic LS plexopahty Bruns-Garland syndrome) ASYMMETRIC NEUROPATHY

18.  involve anterior part of thigh (L1-L4 root)  weakness of iliopsoas, quardriceps, hip adductor  decrease knee jerk, loss sensation in anterior part of thigh  onset 1-15 days, recovery about 6 months  may be recurrent  overlap with distal symmetrical neuropathy 60% ASYMMETRIC NEUROPATHY Lumbrosacral radiculopathy

19. Mononeuropathy ASYMMETRIC NEUROPATHY  involve in single nerve from infarction (acute and focal pain) or entrapment  follow by weakness, atrophy, sensory loss  slow recovery and incomplete  involve median = carpal tunnel syndrome ulnar = cubital tunnel syndrome femoral = foot drop cranial nerve = CN III, CN VII (Bell’s)

20. Mononeuropathy ASYMMETRIC NEUROPATHY CARPAL TUNNEL SYNDROME

21. Symmetric polyneuropathy Asymmetric polyneuropathy Combination  Diabetic cachexia CLASSIFICATION

22. Symmetric polyneuropathy Asymmetric polyneuropathy Combination  Diabetic cachexia CLASSIFICATION

23. Diabetic cachexia  unusual symptom in male, DM type 2  massive BW loss  with painful neuropathy, autonomic  Polyradiculopathy + peripheral neuropathy COMBINATION NEUROPATHY