Pancreas

The Pancreas

The pancreas is partially hidden behind the stomach and sits in front of the kidney and adrenal glands. The tip of the tail of the pancreas touches the spleen.

The pancreas is a dual-purpose gland with both digestive and endocrine functions. The bulk of the gland consists of acinar cells, which produce enzymes used in digestion. Scattered among the cells are about one million pancreatic inlets, cell clusters that produce pancreatic hormone. There are four different types of hormone producing cells. Beta cells make insulin, which enhances transport of glucose into cells, where it is used for energy or converts into glycogen for storage. This way these cells lower blood glucose levels. Alpha cells secrete glucagon, which has the opposite effect of insulin, stimulating release of glucose from the liver in raising blood glucose levels. Somatostatin, secreted by the delta cells, regulates alpha and beta cells. There are only a few F cells. They secrete the pancreatic peptide, which inhibits secretion of bile and pancreatic digestive enzymes.

Acute Pancreatitis

Overview

Acute Pancreatitis is inflammation of the pancreas. Acute pancreatitis is a rapid-onset inflammation of the pancreas, most frequently caused by alcoholism or gallstones.

Causes of Acute Pancreatitis

The chief causes of acute pancreatitis in adults are gallstones, other gallbladder (biliary) disease, and alcohol use. Viral infection (mumps, coxsackie B, mycoplasma pneumonia, and campylobacter), hereditary conditions, traumatic injury, pancreatic or common bile duct surgical procedures and certain medications (especially estrogens, corticosteroids, thiazide diuretics, and azathioprine) are other causes. Pancreatitis without any apparent cause is known as idiopathic pancreatitis. The exact cause of acute pancreatitis may differ among different patients, but in general it is not well understood. It is thought that enzymes normally secreted by the pancreas in an inactive form become activated inside the pancreas and start to digest the pancreatic tissue. This process is called autodigestion and causes swelling, hemorrhage, and damage to the blood vessels. An attack may last several days and the pain may be severe.

Symptoms

• Severe pain in the middle of your upper abdomen, often radiating to the back.
• Nausea
• Vomiting
• Diarrhea
• Bloating
• Fever
• Clammy Skin
• Mild Jaundice

Testing

• serum amylase and lipase
• liver function tests
• blood calcium test
• blood glucose test
• complete blood count
• urinalysis
• Your abdomen and chest may be x-rayed to confirm whether your symptoms are caused by acute pancreatitis or by other disorders that can cause similar symptoms. In addition, the following tests may be done to detect changes in the size of your pancreas:
• ultrasound exam
• endoscopic retrograde cholangiopancreatography (ERCP), an exam in which the doctor inserts an endoscope, an instrument with a light, into your throat and guides it through your stomach and into your small intestine
• CT scan.

Treatment

Treatment for acute pancreatitis depends on the severity of the condition. Generally the patient needs hospitalization with administration of intravenous fluids to help restore blood volume. Medication for pain and nausea are provided to ease these symptoms and food is withheld until these symptoms have subsided considerably. Antibiotics are often prescribed in cases of severe acute pancreatitis or if infection occurs. Surgery is sometimes needed when complications such as infection, cysts or bleeding occur.

Chronic Pancreatitis

Overview

Chronic pancreatitis is an ongoing inflammation of the pancreas, an organ located behind the stomach. This progressive disorder associated with the destruction of the pancreas may be confused with acute pancreatitis due to the similarities of the symptoms. The disease affects men more often than women. Alcohol abuse is an important risk factor.

Causes of Chronic Pancreatitis

• Drinking too much alcohol is the most common cause of chronic pancreatitis. Because of the effects of chronic pancreatitis, the damaged pancreas becomes less able over time to produce normal digestive enzymes and hormones.
• Excess lipids in the blood
• Gallstones, which block the flow of pancreatic secretions into the intestines
• Heredity, in rare cases.

Symptoms

• Upper abdominal pain and back pain with nausea and vomiting are the main symptoms of chronic pancreatitis. As the disease becomes more chronic, patients may develop malnutrition, weight loss and insulin-dependent diabetes.
• The pain is usually a constant, dull pain that gets worse with eating food or drinking alcohol and lessens when sitting up and leaning forward. As the disease progresses, attacks last longer and happen more often. Attacks can last only few hours or as long as several weeks.
• If a large area of the pancreas is damaged, its enzymes are not produced and can’t reach the intestines. As a result, food and nutrients are poorly absorbed. Bowel movements become frequent and foul smelling because of problems with fat absorption.
• If the pancreas is unable to produce the hormone insulin, these symptoms of diabetes mellitus may develop:
• Increased thirst
• Increased appetite
• Increased urination
• Fatigue
• Weight loss.

Testing

The diagnosis of chronic pancreatitis is difficult because routine blood studies (such as amylase and lipase levels) do not necessarily show elevations. The most important clue to a proper diagnosis is an accurate medical history. There are many diagnostic tests that can be used for chronic pancreatitis. The evaluation should begin with a plain film of the abdomen. The finding of pancreatic calcification is virtually diagnostic of chronic pancreatitis but quite often this is not found. Tests the doctor may use to confirm the diagnosis include:

• Ultrasonography
• CT scan
• ERCP (Endoscopic retrograde cholangiopancreatography) –A method for taking x-rays of the common bile duct and the pancreatic ducts. The doctor passes a long, flexible tube called an endoscope down the throat, through the stomach, and into the small intestine. The doctor then injects dye into the ducts and takes x-rays.
• EUS (Endoscopic Ultrasound) –This is a test that combines ultrasound (sound waves) with an endoscope.
• MRI
• Additional tests may include the glucose tolerance test (a test to measure damage to the cells in the pancreas that make insulin) and a biopsy (an exam of tissue removed from the pancreas).

Treatment

The treatment for chronic pancreatitis depends on the symptoms. However, most therapies focus on pain management and nutritional support. Oral pancreatic enzyme supplements are utilized to aid in the digestion of food. Patients who develop diabetes require insulin to control the blood sugar. It is important to remember that no treatment will help relieve your pain if you drink alcohol. A diet low in fat is necessary and sometimes it is easier for the patient to eat more frequently in much smaller portions. The doctor may recommend surgery to relieve abdominal pain, to restore drainage of pancreatic secretions, or to reduce the frequency of attacks.

Autologous islet cell transplantation is performed when a total pancreatectomy is the best option for the treatment of chronic, hereditary, or recurrent acute pancreatitis. A total pancreatectomy involves removal of the entire pancreas and leaves the patient unable to produce pancreatic enzymes for digestion and insulin for controlling blood glucose (sugar) level. The patient will be required to take supplemental enzymes and may require insulin for the remainder of his or her life.
Islet cell transplantation allows a patient to be treated for the pain of pancreatitis without the very serious side-effects of a total pancreatectomy, including “brittle diabetes” when a person’s blood glucose (sugar) level often swings quickly from high to low and from low to high.

Islet cell transplantation allows a patient to be treated for the pain of pancreatitis without the very serious side-effects of a total pancreatectomy, including “brittle diabetes” when a person’s blood glucose (sugar) level often swings quickly from high to low and from low to high.

Hereditary Pancreatitis

Overview

Hereditary Pancreatitis is a rare inherited condition characterized by recurrent episodes of acute pancreatitis attacks. In about half of these cases the problem progresses to chronic pancreatitis, which is severe scarring of the pancreas. Laboratory tests performed during an attack usually detect high blood levels of amylase and lipase, which are enzymes released from the pancreas. The first attack typically occurs within the first two decades of life, but can begin at any age. In the United States, it is estimated that at least 1,000 individuals are affected with hereditary pancreatitis.

Causes
Hereditary Pancreatitis is a genetic disorder, which means that it is usually passed from one generation to the next.
Genetic Hashimoto’s may be a cause.
The symptoms of Hereditary Pancreatitis are caused by a change to a specific gene. Genes are the packages of information that control how our bodies look and function. A single gene appears to be involved in 60-75% of hereditary pancreatitis families. This gene produces the “cationic trypsinogen” enzyme, which breaks down the proteins present in the foods we eat. (In some research papers cationic trypsinogen is called PRSS1).
When a change to a gene occurs, the gene may no longer function properly. These gene changes are called mutations. Currently, there are two common and more than 6 uncommon cationic trypsinogen gene mutations that are associated with hereditary pancreatitis. The major mutations are known as cationic trypsinogen “R122H”, “N29I”.
Families with Hereditary Pancreatitis might carry one of these mutations, but usually not more than one type of mutation. It is also possible that a family with a strong history of Hereditary Pancreatitis may not carry any of the currently known mutations. For this reason, it is believed that additional genes and mutations that cause Hereditary Pancreatitis are awaiting discovery.
Hereditary Pancreatitis has also been linked to an increased lifetime risk of pancreatic cancer.

Symptoms

• Chronic abdominal pain
• Diarrhea
• Nausea
• Vomiting
• Malnutrition
• Diabetes

Testing

• Genetic testing
• serum amylase and lipase
• liver function tests
• blood calcium test
• blood glucose test
• complete blood count
• urinalysis

Treatment

The treatment for hereditary pancreatitis depends on the symptoms. However, the primary treatment focuses on pain control and pancreatic enzyme replacement. Surgery may be indicated to improve symptoms. Removal of the entire pancreas can be performed to eliminate the source of the problem, however in most cases this results in permanent insulin-dependent diabetes.
Properly treating the thyroid in the case of Genetic Hashimoto’s.

Diabetes Insipidus

Overview

Diabetes Insipidus (DI) is a lack of vasopressin(ADH) production in the brain. Vasopressin acts to increase the volume of blood (intravascular) and decrease the volume of urine produced. A lack of vasopressin therefore causes increased urine production and dehydration. In most cases of DI the lack of vasopressin production is from an unknown cause. When DI is caused by a failure of the kidneys to respond to ADH, the condition is called nephrogenic diabetes insipidus.

ADH is released by the pituitary, but unlike most other pituitary hormones it is produced in the hypothalamus.

When ADH reaches the kidneys, it directs the kidneys to concentrate the urine by returning excess water to the bloodstream and therefore make less urine.

The lack of vasopressin production usually results from some sort of damage to the pituitary gland. The damage to the brain could have been caused by a benign tumor (20 percent of cases), trauma (17 percent of cases), neurosurgery (9 percent of cases) or some rather rare causes which include hemochromatosis, sarcoidosis, and histiocytosis.

Symptoms
Extreme thirst
Excretion of an excessive amount of diluted urine

• Depending on the severity of the condition, urine output can range from 2.6 quarts (about 2.5 liters) a day if you have mild diabetes insipidus to 16 quarts (about15 liters) a day if the condition is severe and if you’re taking in a lot of fluids. In comparison, the average urine output for a healthy adult is 1.6 to 2.6 quarts (about 1.5 to 2.5 liters) a day.

Getting up at night to urinate
Bed wetting
Dehydration

Except for dipsogenic DI, which causes you to retain too much water.
Symptoms of dehydration:

• Dry mouth
• Muscle weakness
• Low blood pressure
• Elevated blood sodium
• Sunken appearance to your eyes
• Fever
• Headache
• High heart rate
• Weight loss

Electrolyte imbalance

• Electrolytes are minerals in your blood — such as sodium, potassium, magnesium, and calcium — that maintain the balance of fluids in your body.
• Symptoms of an electrolyte imbalance
• Headache
• Fatigue
• Irritability
• Muscle pains
• High heart rate
• Increased blood pressure
• Low blood pressure
• Muscle weakness

Since the signs and symptoms of diabetes insipidus can be caused by other conditions, your doctor will perform a number of tests. If your doctor determines you have diabetes insipidus, he or she will need to determine which type of diabetes insipidus you have, because the treatment is different for each form of the disease.

Types of Diabetes Insipidus

The rarest form of central DI is familial neurogenic diabetes insipidus. This form of DI is due to an inherited mutation of the arginine vasopressin-neurophysin II (AVP-NPII) gene, inherited in an autosomal dominant manner.At one point, only 45 families worldwide were known to possess this genetic trait. It is now more widely recognized, although the precise number of people affected with this form of DI is unknown at the present time.

Gestational diabetes insipidus. Gestational diabetes insipidus occurs only during pregnancy and when an enzyme made by the placenta — the system of blood vessels and other tissue that allows the exchange of nutrients and waste products between a mother and her baby — destroys ADH in the mother.

Dipsogenic diabetes insipidus. In this form of DI, also known as primary polydipsia or psychogenic polydipsia, excessive fluid intake leads to suppression of ADH. Drinking too much liquid can be the result of abnormal thirst caused by damage to the thirst-regulating mechanism, situated in the hypothalamus. Diseases such as sarcoidosis can cause such damage. Dipsogenic DI also can be caused by mental illness.

Water intoxication

Excessive fluid intake in dipsogenic diabetes insipidus can lead to water intoxication, a condition that lowers sodium concentration in your blood, which can damage your brain.

Testing

Water deprivation test. This test helps determine the cause of diabetes insipidus. (1) excessive intake of fluid, (2) a defect in ADH production, or (3) a defect in the kidneys’ response to ADH.

You’ll be asked to stop drinking fluids two to three hours before the test so that your doctor can measure changes in your body weight, urine output and urine composition when fluids are withheld. Your doctor may also measure blood levels of ADH during this test. The water deprivation test is performed under close supervision in children and pregnant women to make sure no more than 5 percent of body weight is lost during the test.

Urinalysis. If your urine is less concentrated (meaning the amount of water excreted is high and the salt and waste concentrations are low), it could be due to diabetes insipidus.

Magnetic resonance imaging (MRI). An MRI of the head is a noninvasive procedure that uses a powerful magnet and radio waves to construct detailed pictures of brain tissues. Your doctor may want to perform an MRI to look for abnormalities in or near the pituitary gland.

Genetic screening

If your doctor suspects an inherited form of diabetes insipidus, he or she will look at your family history of polyuria and may suggest genetic screening.

Treatment

Treatment of diabetes insipidus depends on what form of the condition you have. Treatment options for the most common types of diabetes insipidus include:

Central diabetes insipidus. Because the cause of this form of diabetes insipidus is a lack of anti-diuretic hormone (ADH), treatment is usually with a synthetic hormone called desmopressin. You can take desmopressin as a nasal spray, as oral tablets or by injection. The synthetic hormone will eliminate the increase in urination. For most people with this form of the condition, desmopressin is safe and effective. If the condition is caused by an abnormality in the pituitary gland or hypothalamus (such as a tumor), your doctor will first treat the abnormality.

While taking desmopressin, drink fluids only when you’re thirsty. This is because the drug prevents excess water excretion, which means your kidneys are making less urine and are less responsive to changes in body fluids.

In mild cases of central diabetes insipidus, you may need only to increase your water intake. Your doctor may suggest a certain amount of water intake — usually more than 2.6 quarts (about 2.5 liters) a day — to ensure proper hydration.

Nephrogenic diabetes insipidus. This condition is the result of your kidneys not properly responding to ADH, so desmopressin is not a treatment option. Instead, your doctor may prescribe a low-salt diet to help reduce the amount of urine your kidneys make. You’ll also need to drink enough water to avoid dehydration.

The drug hydrochlorothiazide, used alone or with other medications, may improve symptoms. Although hydrochlorothiazide is a diuretic (usually used to increase urine output), in some cases it can reduce urine output for people with nephrogenic diabetes insipidus.

Nephrogenic DI may also be caused by:

• Certain drugs (such as lithium, amphotericin B, and demeclocycline)
• High levels of calcium in the body (hypercalcemia)
• Kidney disease (such as polycystic kidney disease)

Gestational diabetes insipidus. Treatment for most cases of gestational diabetes insipidus is with the synthetic hormone desmopressin. In rare cases, this form of the condition is caused by an abnormality in the thirst mechanism. In these rare cases, doctors don’t prescribe desmopressin.

Dipsogenic diabetes insipidus. There is no specific treatment for this form of DI. However, if the condition is caused by mental illness, treating the mental illness may relieve dipsogenic DI.

Precautions

Prevent Dehydration. Your doctor will suggest how much fluid you may need to take in to avoid becoming dehydrated. Carry water with you at all times. In infants and young children, offer water every two hours, day and night.

Wearing a medical alert bracelet and carry a medical alert card in your wallet in the case of a medical emergency. This way a health care professional will recognize your need for special treatment.

Type 1 Diabetes

Overview

In Type 1 Diabetes, the beta cells of the pancreas no longer make insulin because the body’s immune system has attacked them. Diabetes means your blood glucose, or blood sugar, is too high. Insulin is a hormone that helps glucose gets into your cells to give them energy. Without insulin, too much glucose stays in your blood. Over time, high blood glucose can lead to serious problems with your heart, eyes, kidneys. Stomach and other organs, nerves, gums and teeth.

Type 1 diabetes happens most often in children and young adults but can appear at any age.

Causes

Viral or environmental trigger in genetically susceptible people causes an immune reaction. The body’s white blood cells mistakenly attack the insulin-producing pancreatic beta cells, destroying their ability to produce insulin.

Symptoms

Some people will have no symptoms before they are diagnosed with diabetes.
Others may notice these symptoms as the first signs of type 1 diabetes, or when the blood sugar is high:

• Feeling tired or fatigued
• Feeling hungry
• Being very thirsty
• Urinating more often
• Having sores that heal slowly
• Having dry, itchy skin
• Losing weight without trying
• Blurry vision that comes and goes
• Losing the feeling or tingling in your feet or hands or fingers

For others, warning symptoms that they are becoming very sick may be the first signs of type 1 diabetes, or may happen when the blood sugar is very high:

• Deep, rapid breathing
• Dry skin and mouth
• Flushed face
• Fruity breath odor
• Nausea or vomiting, unable to keep down fluids
• Stomach pain
• High heart rate
• Hot flashes
• Sweating

Low blood sugar(hypoglycemia) can develop quickly in people with diabetes who are taking insulin. Symptoms typically appear when the blood sugar level falls below 70 mg/dL. Watch for:

• Headache
• Hunger
• Nervousness
• Rapid heartbeat (palpitations)
• Shaking
• Sweating
• Weakness
• Tunnel vision or blackness surrounding field of vision

Testing

GAD 65 – Glutamic Acid Decarboxylase-65 Autoantibodies
Fasting blood glucose level — diabetes is diagnosed if it is higher than 126 mg/dL on two occasions. But should be suspected if over 110 ever.
Random (nonfasting) blood glucose level — diabetes is suspected if it is higher than 140 mg/dL, and the patient has symptoms such as increased thirst, urination, and fatigue (this must be confirmed with a fasting test)
Oral glucose tolerance test– diabetes is diagnosed if the glucose level is higher than 140 mg/dL after 2 hours.
Hemoglobin A1c test– this test has been used in the past to help patients monitor how well they are controlling their blood glucose levels. Normal A1c is 5.0-5.4 , 5.5 to 5.9 is a strong indication a person is becoming Diabetic and 6.0 is diagnositc.

Ketone testing is also used in type 1 diabetes. Ketones are produced by the breakdown of fat and muscle. They are harmful at high levels. The ketone test is done using a urine sample. Ketone testing is usually done at the following times:

• When the blood sugar is higher than 240 mg/dL
• During an illness such as pneumonia, heart attack, or stroke
• When nausea or vomiting occur
• During pregnancy

Treatment

The immediate goals of treatment are to treat diabetic ketoacidosis and high blood glucose levels. Because type 1 diabetes can come on suddenly and the symptoms can be severe, newly diagnosed people may need to stay in the hospital.
The long-term goals of treatment are to:

• Reduce symptoms
• Stabilize glucose to normal levels
• Prevent diabetes-related complications such as blindness, kidney failure, nerve damage, amputation of limbs, and heart disease

You are the most important person in managing your diabetes. You should know the basic steps to diabetes management:

• How to recognize and treat low blood sugar (hypoglycemia)
• How to recognize and treat high blood sugar (hyperglycemia)
• Diabetes meal planning
• How to give insulin
• How to monitor blood glucose and urine ketones
• How to adjust insulin and food intake during exercise
• How to handle sick days
• Where to buy diabetes supplies and how to store them

Insulin lowers blood sugar by allowing it to leave the bloodstream and enter cells. Everyone needs insulin. People with type 1 diabetes can’t make their own insulin. They must take insulin every day.
Insulin is usually injected under the skin. In some cases, a pump delivers the insulin continuously. Insulin does not come in pill form.
Insulin preparations differ in how fast they start to work and how long they last. The health care professional will review your blood glucose levels to determine the appropriate type of insulin you should use. Best control is possible with using separate long acting insulin such as Lantus and short acting ones for glucose spikes and meals. Mixed inuslins cannot accomplish this.
The injections are needed, in general, from two to six times a day. People are taught how to give insulin injections by their health care provider or a diabetes nurse educator. At first, a child’s injections may be given by a parent or other adult. By age 14, most children can be expected (but should not be required) to give their own injections.
People with diabetes need to know how to adjust the amount of insulin they are taking in the following situations:

• When they exercise
• When they are sick
• When they will be eating more or less food and calories
• When they are traveling

DIET
People with type 1 diabetes should eat at about the same times each day and try to be consistent with the types of food they choose. These foods should be low carbohydrate, good fats and good protein. This helps to prevent blood sugar from becoming extremely high or low.

PHYSICAL ACTIVITY
Regular exercise helps control the amount of sugar in the blood. It also helps burn excess calories and fat to achieve a healthy weight.
Ask your health care provider before starting any exercise program. Those with type 1 diabetes must take special precautions before, during, and after intense physical activity or exercise.

• Always check with your doctor before starting a new exercise program.
• Ask your doctor or nurse if you have the right footwear.
• Choose an enjoyable physical activity that is appropriate for your current fitness level.
• Exercise every day and at the same time of day, if possible.
• Monitor your blood glucose levels at home before and after exercising.
• Carry Glucose Tablets in case your blood glucose levels get too low during or after exercise.
• Wear a diabetes identification bracelet and carry a cell phone to use in case of emergency.
• Drink extra fluids that do not contain sugar before, during, and after exercise.
• As you change the intensity or duration of your exercise, you may need to modify your diet or medication to keep your blood glucose levels in an appropriate range.

SELF-TESTING
Self-testing refers to being able to check your blood sugar at home yourself with a glucometer. Regular self-testing of your blood sugar tells you and your health care provider how well your diet, exercise, and diabetes medications are working.

• Your doctor will help you set a goal for what level your blood sugar should be during the day.
• The results can be used to adjust meals, activity, or medications to keep blood sugar levels within an appropriate range. Tests are usually done before meals, two hours after meals, at rising and one hour after rising and at bedtime. More frequent testing may be needed when you are sick, under stress, or adjusting your insulin dosing.

Testing will identify high and low blood sugar levels before serious problems develop.

Keeping accurate records of your test results will help you and your health care provider plan how to best control your diabetes.
The American Diabetes Association recommends keeping blood sugar levels in a range that is based on your age. Discuss these goals with your physician and diabetes educator.
Before meals:

• 70 – 100 mg/dL for adults
• 100 – 180 mg/dL for children under age 6
• 90 – 180 mg/dL for children 6 – 12 years old
• 90 – 130 mg/dL for children 13-19 years old

At bedtime:

• Less than 140mg/dL for adults
• 110 – 200 mg/dL for children under age 6
• 100 – 180 mg/dL for children 6 – 12 years old
• 90 – 150 mg/dL for children 13 – 19 years old

FOOT CARE
Diabetes causes damage to the blood vessels and nerves. This can reduce your ability to feel injury to or pressure on the foot. You may not notice a foot injury until severe infection develops. Diabetes can also damage blood vessels. Small sores or breaks in the skin may progress to deeper skin ulcers. Amputation of the affected limb may be needed when these skin ulcers do not improve or become larger or deeper.
To prevent problems with your feet, you should:

• Stop smoking if you smoke.
• Improve control of your blood sugar.
• Get a foot exam by your health care provider at least twice a year and learn whether you have nerve damage.
• Check and care for your feet EVERY DAY, especially if you already have known nerve or blood vessel damage or current foot problems.
• Make sure you are wearing the right kind of shoes.

TREATING LOW BLOOD SUGAR
Hypoglycemia can develop quickly in people with diabetes. Symptoms typically appear when the blood sugar level falls below 70 mg/dL. If you have symptoms:

• Do a blood sugar check.
• If the level is low or you have symptoms of hypoglycemia, eat Glucose Tablets. They are meant for this purpose and can correct hypoglycemia faster and more accurately without over shooting your target glucose reading. They should be carried with you at all times and in every room in your house in case you can not walk to get to them. Overtreating a mild low blood sugar reaction can lead to problems with high blood sugar and difficult blood sugar control overall.
• Symptoms should go away within 15 minutes. If the symptoms don’t go away, repeat the Glucose Tabs as above, and test the sugar level again. When your blood sugar is in a safer range (over 70 mg/dL), you may need to eat a snack with carbohydrates and protein, such as cheese and crackers or a glass of milk.

Ask your doctor if you need a glucagon injection kit to raise blood sugar quickly in an emergency.

Expectations (prognosis)

Diabetes is a lifelong disease for which there is not yet a cure. However, the outcome for people with diabetes varies. Studies show that tight control (Maintaining an A1c of 5.5 or less) of blood glucose can prevent or delay complications to the eyes, kidneys, nervous system, and heart in type 1 diabetes.

Complications
After many years, diabetes can lead to serious problems with your eyes, kidneys, nerves, heart, blood vessels, and other areas in your body.
If you have diabetes, your risk of a heart attack is the same as someone who has already had a heart attack. Both women and men with diabetes are at risk. You may not even have the typical signs of a heart attack.
In general, complications include:

• Cataracts
• Damage to the blood vessels that supply the legs and feet (peripheral vascular disease)
• Foot sores or ulcers, which can result in amputation
• Glaucoma
• High blood pressure
• High cholesterol
• Kidney disease and kidney failure (diabetic nephropathy)
• Macular edema
• Nerve damage, which causes pain and numbness in the feet, as well as a number of other problems with the stomach and intestines, heart, and other body organs (diabetic neuropathy)
• Stroke
• Worsening of eyesight or blindness due to diabetic retinopathy (eye disease)

Other complications include:

• Erection problems
• Infections of the skin, female genital tract, and urinary tract

Type 2 Diabetes

Overview

In Type 2 diabetes, the pancreas loses the ability to secrete enough insulin in response to meals.

When you have type 2 diabetes, the body does not respond correctly to insulin. This is called insulin resistance. Insulin resistance means that fat, liver, and muscle cells do not respond normally to insulin. As a result blood sugar does not get into cells to be stored for energy.

When sugar cannot enter cells, abnormally high levels of sugar build up in the blood. This is called hyperglycemia. High levels of blood sugar often trigger the pancreas to produce more and more insulin, but it is not enough to keep up with the body’s demand.

Causes
People who are overweight are more likely to have insulin resistance, because fat interferes with the body’s ability to use insulin.
Type 2 diabetes usually occurs gradually. Most people with the disease are overweight at the time of diagnosis. However, type 2 diabetes can also develop in those who are thin, especially the elderly.
Family history and genetics play a large role in type 2 diabetes. Low activity level, poor diet, and excess body weight (especially around the waist) significantly increase your risk for type 2 diabetes.
Other risk factors include:

• Age greater than 45 years
• HDL cholesterol of less than 35 mg/dL or triglyceride level of greater than 250 mg/dL
• High blood pressure
• History of gestational diabetes
• Polycystic ovarian syndrome
• Previously identified impaired glucose tolerance by your doctor
• Race/ethnicity (African Americans, Hispanic Americans, and Native Americans all have high rates of diabetes)
• Hypothyroidism
• Adrenal insufficency
• Menopause
• Andropause

Symptoms
Often, people with type 2 diabetes have no symptoms at all. If you do have symptoms, they may include:

• Blurred vision
• Erectile dysfunction
• Fatigue
• Frequent or slow-healing infections
• Increased appetite
• Increased thirst
• Increased urination

Testing
Type 2 diabetes is diagnosed with the following blood tests:

• Fasting blood glucose level– diabetes is diagnosed if higher than 100 mg/dl on two different blood test. (The recommendation of the main stream medical community and an excellent reason why so many have diabetes is 126 mg/dL).
• Hemoglobin A1c test– this test has been used in the past to help patients monitor how well they are controlling their blood glucose levels. In 2010, the American Diabetes Association recommended that the test be used as another option for diagnosing diabetes and identifying pre-diabetes. Levels indicate:

• Normal: Less than 5.7%
• Pre-diabetes: Between 5.7% – 6.4%
• Diabetes: 6.5% or higher

Here again is where the main stream medical community is causing diabetes. The levels should be

• Normal: Less then 5.4%
• Pre-diabetes : between 5.5% – 5.9%
• Diabetes: 6.0%

• Oral glucose tolerance test — diabetes is diagnosed if glucose level is higher than 200 mg/dL after 2 hours. Here again this level should be 140 not 200.
• Random (non-fasting) blood glucose level — diabetes is suspected if higher than 200 mg/dL and accompanied by the classic symptoms of increased thirst, urination, and fatigue (this test must be confirmed with a fasting blood glucose test).

Better diabetes experts believe a normal person should never have glucose over 140 and 2-3 hours after meals it should have returned to pre-meal levels.

Treatment
The immediate goal of treatment is to lower high blood glucose levels. The long-term goals of treatment are to prevent diabetes-related complications.
The primary treatment for type 2 diabetes is exercise and diet.

SELF-TESTING
Self testing refers to being able to check your blood sugar at home yourself. It is also called self-monitoring of blood glucose (SMBG). Regular self-testing of your blood sugar tells you and your health care provider how well your diet, exercise, and diabetes medications are working.
A device called a glucometer can provide an exact blood sugar reading.

The results of the test can be used to adjust meals, activity, or medications to keep your blood sugar levels in an appropriate range. Testing can identify high and low blood sugar levels before serious problems develop.

DIET AND WEIGHT CONTROL
People with type 2 diabetes should eat at about the same times each day and try to be consistent with the types of food they choose. This helps to prevent blood sugar from becoming extremely high or low. Meal planning includes choosing healthy foods, eating the right amount of food, and eating meals at the right time. You meals should be low carb, low sugar, good fats and meats. Managing your weight and eating a well-balanced diet are important. Some people with type 2 diabetes can stop taking medications after losing weight (although they still have diabetes).

Regular exercise is important for everyone, but especially if you have diabetes. Regular aerobic exercise lowers your blood sugar level without medication and helps burn excess calories and fat so you can manage your weight.

Exercise can help your overall health by improving blood flow and blood pressure. It decreases insulin resistance even without weight loss. Exercise also increases the body’s energy level, lowers tension, and improves your ability to handle stress.

Autoimmune Pancreatitis

Overview

Autoimmune pancreatitis is a rare disease and can be mistakenly diagnosed as pancreatic cancer. Both conditions have similar signs and symptoms, but very different treatments, so it is crucial to distinguish one from another. Autoimmune pancreatitis is treated with steroids, which improve the condition in many people, often dramatically.

Autoimmune pancreatitis is a chronic inflammation thought to be caused by the body’s immune system attacking the pancreas. The disease affects not only the pancreas, but also the bile ducts in the liver, as well as the salivary glands, kidneys and lymph nodes. One type of the disease mainly affects men in their 50s and 60s; a second type can occur in children as young as 12.

Data suggest that autoimmune pancreatitis affects men twice as often as it affects women. While the disease can strike people in their early thirties, it most commonly affects people in their fifties or sixties. Autoimmune pancreatitis may occur independent of other disorders; however, it’s been associated with disorders, such as sclerosing cholangitis, primary biliary cirrhosis, inflammatory bowel disease, rheumatoid arthritis, hypothyroidism, sarcoidosis, and Sjogren’s syndrome.

Symptoms

• Dark-colored urine that resembles cola or dark tea
• Dehydration
• Diabetes mellitus
• Excess bilirubin
• Fever
• High blood glucose
• Internal bleeding
• Jaundice
• Low blood pressure
• Nausea
• Pain or tenderness of the pancreas
• Rapid pulse
• Swelling of the pancreas
• Vomiting
• Weight loss
• Yellow tinting of the skin and the white area around the pupil
• As the condition worsens, the yellow tint turns a brownish color

Testing

Autoimmune pancreatitis (AIP) can be particularly challenging to diagnose because the way it presents itself closely resembles pancreatic cancer. The most common sign, present in about 80 percent of people, is painless jaundice, caused by blocked bile ducts. AIP can also cause weight loss. Masses in the pancreas and other organs of many people with autoimmune pancreatitis can be misdiagnosed as cancer.

No single test or characteristic feature identifies autoimmune pancreatitis.

Suspicion of autoimmune pancreatitis often results in lab tests. Results may show elevated blood sugar levels, as approximately half of patients with autoimmune pancreatitis recently developed diabetes mellitus. In addition, lab tests often reveal elevations in the level of serum gamma globulin or IgG4. There may also be an increase in serum autoantibodies, including anti-lactoferrin antibody, anti-carbonic anhydrase II antibody, and rheumatoid factor. In addition, the histopathological samples from the pancreas reveal lymphocytes and plasma cells.

• Imaging tests. Imaging of the pancreas and other organs is usually the first step in diagnosis. Such as dual-phase helical CT scans and MRI, which produce superior images of the pancreas, bile ducts and liver. It is essential to have images read by radiologists with expertise in pancreatic disorders.
• Blood tests. Elevated levels of an antibody called IgG4 are a common feature of autoimmune pancreatitis. But a positive test doesn’t mean that you have the disease.
• Endoscopic core biopsy. Pathologists analyze a sample of pancreatic tissue in the laboratory to help confirm the diagnosis of autoimmune pancreatitis. The disease has a distinctive appearance that is easily recognized under a microscope. The challenge is obtaining a sample of whole tissue large enough to analyze.
• Steroid trial. Because autoimmune pancreatitis is the only pancreatic disorder known to respond to corticosteroids, doctors sometimes use a trial course of this drug to confirm a diagnosis. If your signs and symptoms improve — for instance, your IgG4 level drops or a mass in your pancreas shrinks — you are considered to have autoimmune pancreatitis. However, this approach should be used only by doctors thoroughly familiar with the disease, as steroids give a general feeling of well-being even in people with cancer. Also, elevation of IgG4 not associated with AIP may also decrease with steroid use, giving a false sense of reassurance.

Treatment

Symptoms of autoimmune pancreatitis often improve after a short course of corticosteroids. Many people respond quickly, even dramatically. Some people get better without any treatment. However, about 30 to 40 percent of the time, the disease returns (relapses), requiring additional treatment, and sometimes long term treatment.
Autoimmune pancreatitis can be associated with other organ involvement, including enlarged lymph nodes and salivary glands, scarring of the bile ducts, liver inflammation, and kidney disease. Although these manifestations may diminish or disappear completely with steroid therapy, your doctor should continue to monitor you for recurring problems.

Autoimmune pancreatitis: an update on classification, diagnosis, natural history and management.
http://www.ncbi.nlm.nih.gov/pubmed/22350841