1. Difficult Case on T2Diabetes Management 2
Dr bounmy SOMSAMOUTH
Chief of endocrinology Setthathirath Hospital

2. Case 2
A 34 years old Lao women. who was diagnosed as having type 2 diabetes 8 year ago. She has mild hypertension but no evidence of coronary disease or other complication of diabetes. She is managed with insulin 2 year and poor control of hyperglycemia; recent A1c from 10-12%
One year ago, the Pt began having episodic nausea and vomiting. The problem increased in frequency, for the past 6 months some degree of nausea and vomiting has been present daily.

3. Symptoms
Occur most commonly in the morning and with eating, when early satiety, bloating, and fullness also are present. Associated with dizzy, fatigue, loss of appetite, vision Loss and neck pain
No fever, cough, weight loss.

4. Physical Examination Good mental state
General condition: moderate dehydration
Vital signs :
Bp 120/90 mmHg, pulse bpm,
Heart: tachycardia, lungs : normal ,abdominal soft
Mild edema at the face
Dorsalispedis pulse: normal, loss sensory and mild numbness

5. What do you think? Differential Diagnosis?
DKA?
HHS?
Chronic gastritis?
PUD?
CA gastric?
Diabetic neuropathy(Diabetic gastro paresis)?
Medication ?

6. Investigation CBC Electrolyte
Glucose, BUN, Creatinine, cholesterole, triglyceride, liver function.
Endoscopy
CT abdomen

7. Result investigation Date .month. year Result Glycemia 123,146,130 BUN
15mg,17mg, 16mg/dl
Creatinine
1.8mg,1.3mg,1,3mg/dl
Cholesterole
400mg/dl
Triglyceride
81mg/dl
A1c
7,2%
CBC
HGB7.8g/dl HCT23%,PTL
299,000
U/A
Protein500mg/dl,Glucose 1000mg/dl,Ery 50
Gastroscopy
Normal
Ultrasound Abdominal
Fundus copy
NPDR(non proliferative retinopathy)

8. Final Diagnosis?
Diabetic gastro paresis ?

9. What is Gastroparesis?
Gastroparesis means weakness of the muscles of the stomach.
ແມ່ນຄວາມຜິດປົກະຕິຂອງລະບົບປະສາດ ແລະກ້າມຊີ້ນຂອງກະເພາອາຫານ.
ໝາຍເຖິງການຂັບເຄື່ອນອາຫານຈາກກະເພາະຫາລຳໃສ້ຊ້າກວ່າ
ປົກະຕິ ເປັນສາເຫດເຮັດໃຫ້ກະເພາະອາຫານເຕັມຕະຫຼອດ
ຄວາມຜິດປົກະຕິດັ່ງກ່າວ:
Gastricdysrhythmias,
Antral hypomotility
Incoordination of antroduodenal contractions
Gastroparesis

10. Causes of gastroparesis
• Diabetes
• Surgery involving any of the digestive organs, such as the stomach and bowels
• Certain medicines, such as strong pain medicines (narcotics)
• Certain conditions, such as systemic scleroderma, Parkinson disease, and thyroid disease
• After a viral illness

11. How should we know ?
First, many of the people with gastroparesis have long-standing diabetes and evidence of damage to other organs
Second, many of these people have other symptoms of neuropathies(mono neuropathy, peripheral neuropathy)

12. Symptoms of GP
Nausea and vomiting up partially digested food that has been sitting in the stomach
Dry heaves
Abnormal bloating
Abdominal pain
Loss of appetite
The feeling of filling up too quickly while eating

13. Gastroparesis Diagnosis
Upper gastrointestinal x-ray, and a gastroscopy
Rule out other diseases such as ulcer, gastritis and gastric cancer, pyloric stenosis ,and et …
50% of diabetics may show signs of gastroparesis
Another investigation

14. Final Diagnosis
Diabetic gastro paresis

15. How should we treatment?
Control blood glucose level
High blood glucose levels can slow stomach emptying and add to the problem.
Dietary
Eat small meals throughout the day rather than a few larger ones.
Cut back on fatty foods, cut back on difficult to digest foods: legumes, lentil, and citrus fruits

16. How should we treatment? cont
Medication
Metoclopramide
Which acts on the nervous system to increase the strength and frequency of gastrointestinal muscle contraction.
It taken minutes before mean and at bedtime
Domperidone
Improves stomach emptying by stimulating stomach motor activity

17. Management cont Other conventional antiemetic agents Neuropsychiatric
Prochlorperazine, promethazine (phenergan)
antispasmodics
Neuropsychiatric
Antidepressants
Amitriptyrine
Erythromycin is a commonly used antibiotic that binds to receptors in the stomach and small intestine called “motilin receptors

18. Surgery The most popular option is ajejunostomy tube

19. Gastro paresis Prognostic
When a diabetic gastro paresis will get better
Some people with this disease will have to be hospitalized regularly.
After some months or years, the disease seems to burn itself out and the person improves

20. ສະຫຼຸບ
ຄົນເຈັບທີ່ເປັນເບົາຫວານສົມທົບກັບອາການປວດຮາກ ແລະຮາກຄິດຫາ Diabetic gastropathy.
ຄົນເຈັບເບົາຫວານຕ້ອງຄຸມນ້ຳຕານໃຫ້ຢູ່ເກນປົກະຕິເພື່ອຫຼີກລ໊ຽງການເປັນ diabetic gastroparesis ແລະອາການສົນອຶ່ນໆ
ການປິ່ນປົວ diabetic gastroparesis:
ຄຸມນ້ຳຕານໃຫ້ຢູ່ເກນປົກະຕິ
ປະສະຈາກອາຫານມັນ,ໃຍ, ແກ່ນໝາກໃມ້ ອາຫານມິລົດສົ້ມ ແລະເທື່ອລະນ້ອຍ
ການໃຫ້ຢາປິ່ນປົວອາການ
ການຜ່າຕັດ

21. Thank you For Your attention