Anatomy and Physiolog2

8/9/2019 Anatomy and Physiolog2

1/17

ANATOMY AND PHYSIOLOGY

WHAT IS PANCREAS?

PANCREAS

y An accessory digestive organ with both exocrine (digestive enzymes) and endocrine (hormones) function,found about the epigastric and left hypochondriac areas along the transpyloric plane.

o Exocrine- secretions find their way outside the bodyo Endocrine- secretions are secreted into the bloodstream

y Retroperitoneal in position, found posterior to the stomach, forms part of the stomach bedy A tapered yellowish organ about 7 long and 1.5 widey Transversely located between the duodenum on the right and spleen on the leftIs a gland organ in the digestive and endocrine system of vertebrates. It is both an endocrine gland producing

several important hormones, including insulin, glucagon, andsomatostatin, as well as an exocrine gland,

secreting pancreatic juice containing digestive enzymes that pass to the small intestine. These enzymes help to

further breakdown thecarbohydrates, proteins, and fats in the chyme.

A fish-shaped spongy grayish-pink organ about 6 inches (15 cm) long that stretches across the back of theabdomen, behind the stomach. The head of the pancreas is on the right side of the abdomen and is connected to

the duodenum (the first section of the small intestine). The narrow end of the pancreas, called the tail, extends to

the left side of the body.

The pancreas makes pancreatic juices and hormones, including insulin. The pancreatic juices are enzymes

that help digest food in the small intestine. Insulin controls the amount of sugar in the blood. As pancreatic juices

are made, they flow into the main pancreatic duct. This duct joins the common bile duct, which connects the

pancreas to the liver and the gallbladder. The common bile duct, which carries bile (a fluid that helps digest fat),

connects to the small intestine near the stomach.


2/17

The pancreas is thus a compound gland. It is "compound" in the sense that it is composed of both

exocrine and endocrine tissues. The exocrine function of the pancreas involves the synthesis and secretion of

pancreatic juices. The endocrine function resides in the million or so cellular islands (the islets of Langerhans)

embedded between the exocrine units of the pancreas. Beta cells of the islands secrete insulin, which helps control

carbohydrate metabolism. Alpha cells of the islets secrete glucagon that counters the action of insulin.

Under a microscope, stained sections of the pancreas reveal two different types of parenchymal tissue.

Lightly staining clusters of cells are called islets of Langerhans, which produce hormones that underlie the

endocrine functions of the pancreas. Darker staining cells form acini connected to ducts. Acinar cells belong to the

exocrine pancreas and secrete digestive enzymes into the gut via a system of ducts.

Structure Appearance Function

Islets of

Langerhans

Lightly staining, large, spherical

clusters

Hormone production and secretion (endocrine

pancreas) These are the endocrine (endo=

within) cells of the pancreas that produce and

secrete hormones into the bloodstream. The

pancreatic hormones, insulin and glucagon,

work together to maintain the proper level ofsugar in the blood. The sugar, glucose, is used

by the body for energy.

Pancreatic acini Darker staining, small, berry-like

clusters

Digestive enzyme production and secretion

(exocrine pancreas) These are the exocrine

(exo= outward) cells of the pancreas that

produce and transport chemicals that will exit

the body through the digestive system. The

chemicals that the exocrine cells produce are

called enzymes. They are secreted in the

duodenum where they assist in the digestion of

food.

WHERE IS THE PANCREAS?

The pancreas is located deep in the abdomen, sandwiched between the stomach and the spine. It lies

partially behind the stomach. The other part is nestled in the curve of the duodenum (small intestine). To visualize

the position of the pancreas, try this: Touch the thumb and "pinkie" finger of your right hand together, keeping the

other three fingers together and straight. Then, place your hand in the center of your belly just below your lower

ribs with your fingers pointing to the left. Your hand will be at the approximate level of your pancreas.


3/17

Because of the pancreas' deep location, tumors are rarely palpable (able to be felt by pressing on the

abdomen.) It also explains why many symptoms of pancreatic cancer often do not appear until the tumor grows

large enough to interfere with the function of nearby structures such as the stomach, duodenum, liver, or

gallbladder.

WHAT ARE THE PARTS OF PANCREAS?

y Heady Uncinate processy Necky Bodyy Tail

uncinate

process

The part of the gland that bends backwards and underneath the body of the pancreas.

Two very important blood vessels, the superior mesenteric artery and vein cross in front

of the uncinate process.

head The widest part of the gland. It is found in the right part of abdomen, nestled in thecurve of the duodenum which forms an impression in the side of the gland.

neck The thin section between the head and the body of the gland.

body The middle part of gland between the neck and the tail. The superior mesenteric blood

vessels run behind this part of the gland.

tail The thin tip of gland in the left part of abdomen in close proximity with the spleen.


4/17

FUNCTIONS OF PANCREAS

The Pancreas is connected to the duodenum via two ducts and has two main functions:

y To produce enzymes to aid the process of digestion.y To release insulin directly into the blood stream for the purpose of controlling blood sugar levels.The pancreas is an integral part of the digestive system. The flow of the digestive system is often altered

during the surgical treatment of pancreatic cancer. Therefore it is helpful to review the normal flow of food before

reading about surgical treatment. Food is carried from the mouth to the stomach by the esophagus. This tube

descends from the mouth and through an opening in the diaphragm. (The diaphragm is a dome shaped muscle

that separates the lungs and heart from the abdomen and assists in breathing.) Immediately after passing through

the diaphragm's opening, the esophagus empties into the stomach where acids that break down the food are

produced. From the stomach, the food flows directly into the first part of the small intestine, called the duodenum.

It is here in the duodenum that bile and pancreatic fluids enter the digestive system.

BILE PANCREATIC FLUID

Bile is a greenish-yellow fluid that aids in the digestion of fats. After being produced by cells in the liver,

the bile travels down through the bile ducts which merge with the cystic duct to form the common bile duct. The

cystic duct runs to the gallbladder, a small pouch nestled underneath the liver. The gallbladder stores extra bile

until needed. The common bile duct actually enters the head of the pancreas and joins the pancreatic duct to form

the ampulla of Vater which then empties into the duodenum. Flow of bile indicated by green arrows.

Instead of carrying bile, the pancreatic duct carries the pancreatic fluid produced by the acinar cells

(exocrine) of the pancreas. The pancreatic duct runs the length of the pancreas and joins the common bile duct in

the head of the pancreas. These ducts join to form the ampulla of Vater which then empties into the duodenum.Flow of pancreatic fluid indicated by dark yellow arrow.

The food, bile and pancreatic fluid travels through many more feet of continuous intestine including the

rest of the duodenum, jejunum and ileum which comprise the small intestine, then through the cecum, large

intestine, rectum, and anal canal.


5/17

The pancreas is a dual-function gland. While most glands are either exocrine or endocrine, the pancreas has

both exocrine and endocrine functions. Exocrine glands secrete substances outside the body or into the gut, while

endocrine glands secrete substances into the blood. Consequently, the physiology of the pancreas can be

considered in the context of the substances that the pancreas releases into the gut (it does not excrete substances

outside the body) or into the blood. The pancreas has digestive and hormonal functions:

Digestive function: From pancreas some enzymes are secreted which take part in the food metabolism of

our body. These enzymes help break down carbohydrates, fats, proteins, and acids in the duodenum.

Hormonal function:The hormones secreted by the pancreas are insulin, glucagon and somatostatin. We

already have known that insulin and glucagon regulate the level of glucose in the blood. Somatostatin can inhibit

both insulin and glucagon secretion.

Enzymes suspended in the very alkaline pancreatic juices include amylase for breaking down starch into

sugar, and lipase which, when activated by bile salts, helps to break down fat. The hormone insulin is produced by

specialised cells, the islets of Langerhans, and plays an important role in controlling the level of sugar in the blood

and how much is allowed to pass to the cells. Products from the exocrine portion of the pancreas are called

enzymes and include trypsin, chymotrypsin, pancreatic amylase, and pancreatic lipase. Major products of theendocrine pancreas are called hormones and include insulin, glucagon, and somatostatin.

CELLS OF THE PANCREAS

EXOCRINE PORTION

y acinar cells secrete digestive enzymes and pancreatic juice into the ducts which enter the duodenum andhelp in food digestion

y Digestive enzymes: trypsin, chymotrypsin, pancreatic lipase, and pancreatic amylasey Pancreatic juice: an alkaline fluid rich in bicarbonate and salt

ENDOCRINE PORTION -islets of Langerhans which include:

yalpha cells (A cells) 25%, which secrete glucagon (increases blood glucose)- are endocrine cells in the islets of Langerhans of the pancreas. They make up 33-46% of the human

islet cells and are responsible for synthesizing and secreting the peptide hormone glucagon, which elevates

the glucose levels in the blood.

To elevate glucose levels, glucagon binds to receptors on hepatocytes (liver cells) and other cells (e.g.

muscle cells). This activates an enzyme, glycogenphosphorylase, inside the hepatocyte to

hydrolyse glycogen to glucose. This process is called glycogenolysis. In rodents, alpha cells are located in the

periphery of the islets, however in humans the islet architecture is generally less organized and alpha cells are

frequently observed inside the islets as well. When being viewed by an electron microscope, alpha cells can be

identified by their characteristic granules with a large dense core and a small white halo. Alternative and more

common spellings: alpha-cell or -cell.

y beta cells (B cells) 60%,which secrete insulin (lowers blood glucose)- Beta cells make and release insulin, a hormone that controls the level of glucose in the blood. There

is a baseline level of glucose maintained by the liver, but it can respond quickly to spikes in blood glucose by

releasing stored insulin while simultaneously producing more. The response time is fairly quick, taking

approximately 10 minutes.

Apart from insulin, beta cells release C-peptide, a byproduct of insulin production, into the equimolar

quantities. C-peptide helps to prevent neuropathy and other symptoms of diabetes related to vascular

deterioration. Measuring the levels of C-peptide can give a practitioner an idea of the viable beta cell mass.-

cells also produce amylin, also known as IAPP, islet amyloid polypeptide. Amylin functions as part of the

endocrine pancreas and contributes to glycemic control. Amylin's metabolic function is now somewhat well


6/17

characterized as an inhibitor of the appearance of nutrient [especially glucose] in the plasma. It thus functions

as a synergistic partner to insulin. Whereas insulin regulates long term food intake, increased amylin decreases

food intake in the short term.

y delta cells (D cells) 10%, which secrete somatostatin (inhibitory to release of gastrointestinal andpancreatic hormones, gastric emptying, and intestinal blood flow)

y pp cells 5%,secrete pancreatic polypeptideis a polypeptide secreted by PP cells in the endocrine pancreaspredominantly in the head of the

pancreas. It consists of 36 amino acids The function of PP is to self regulate the pancreas secretion activities

(endocrine and exocrine), it also has effects on hepatic glycogen levels and gastrointestinal secretions. Its

secretion in humans is increased after a protein meal, fasting, exercise, and acutehypoglycemia and is

decreased by somatostatin and intravenous glucose.


7/17

WHAT IS INSULIN?

Insulin is a familiar word as there are many who suffer from diabetes. But most of us might not have

heard of glucagons, which is very much an important substance for our body. The importance of insulin and

glucagon are due to their action in maintaining the balance of blood glucose levels in our body. Glucose is a very

important element for our body. We need energy for our bodily activities. This energy is derived from glucose.

Glucose is the body's primary source of fuel. Whatever food we consume that is transformed into glucose in ourbody. This glucose is than transported to our body cells by blood to be used as energy source. So without glucose

our body will be out of energy source leading to a shutting down of all activities. When we work hard or have not

taken meal for long time we feel hungry. This hunger is the state when our body runs short in glucose and needs

immediate refueling. In this circumstances when we take food, the food gives supply of glucose and our body

glucose comes to a stable situation leading towards the smooth functioning of the body.

How Insulin Affect Blood Glucose

Aids glucose entry into the cells

Stimulates glycogenesis bld

= formation and storage of glycogen

(liver) glucose

Promotes glucose catabolism level

y Decrease transcellular transport of glucosey Require Na for transporty K for productiony Therefore decreased blood glucose level. And inhibits protein and fat breakdown


8/17

Role ofInsulin:

When we take food and glucose is made from the food metabolism, this glucose is than transported to

our body cells by blood to be used as energy source. In this phase we need a hormone named Insulin which assists

the glucose in the blood to enter in the cells. When blood glucose levels rise, cells named beta cells in pancreas

release insulin. Pancreas is an organ located behind our stomach. Without the presence of insulin our body cells

cannot take up the glucose from the blood leading to glucose crisis in the body cells for performing activities. If we

insulin deficit, the process of glucose metabolism begins working improperly. Instead of being transported intobody cells, glucose starts building up in the bloodstream. This situation may occur in two conditions.

y When body cells become resistant to the action of insulin. Exactly why the cells become resistant toinsulin's effects is still not clearly known.

y If there is deficit in glucose production in the body by the glucose producing cells in pancreas.y These two situations can lead towards the disease condition called diabetes mellitus.

Role of Glucagon:

When there is accesses glucose in our body, this glucose is stored for future use by out body as fat cells. If

in any case there is any shortage of glucose in our body and there is no supply available than body goes for the

alternative way to fulfill the deficit. When blood glucose levels fall, cells named alpha cells in pancreas release

glucagon. When blood glucose is high, no glucagon is secreted from the alpha cells. Glucagon has the greatest

effect on the liver although it affects many different cells in the body. When glucose levels are low our liver

releases the stored glucose into the bloodstream to keep blood glucose level within a normal range and Glucagon's

main function is to cause the liver to release stored glucose from its cells into the blood.

Glucose level: insulin and glucagon

Our body requires that the blood glucose level is maintained in a very narrow optimal range. Our body

tries to maintain the blood glucose normally between 70 mg/dl and 110 mg/dl. Blood glucose levels below

70mg/dl, is called "hypoglycemia". A blood glucose level of 180mg/dl or more is called "hyperglycemia". If the

blood glucose is lower than optimal then our body tries to bring it up to the optimal level. Similarly if the body

glucose level is higher than the optimal level then our body tries to bring it down to the optimal level. So according

to the body glucose level, body decides which one to secrete, insulin or glucagon? After a meal, the amount of

insulin secreted into the blood increases as the blood glucose rises. Similarly, as blood glucose falls, insulin

secretion by the pancreatic islet beta cells decreases. On the other hand, glucagon is secreted by the alpha cells of

the pancreas when blood glucose is low. As for example, blood glucose is low between meals and during exercise.So for compensating the need of the body the glucoagon is secreted. Contrary to that, when blood glucose is high,

no glucagon is secreted from the alpha cells. So we see that the insulin and glucagon secretion is coordinated.

Consumption of carbohydrates triggers release of insulin from beta cells.

Alpha cells become inhibited and cease to secrete glucagon. Opposite happens when we have enough glucose

supplied to the body. Major control of blood glucose levels is achieved through actions of the hormones insulin

and glucagon. The slightest rise in plasma glucose leads to a decrease in glucagon secretion and an increase in

insulin secretion. The reverse occurs when plasma glucose levels fall. Maintaining this balance is very important for

our body and any situation leading to the imbalance create disease condition.

WHAT IS DIABETES MELLITUS?

Diabetes mellitus, often simply referred to as diabetesis a group of metabolic diseases in which a

person has high blood sugar, either because the body does not produce enough insulin, or because cells do not

respond to the insulin that is produced. This high blood sugar produces the classical symptoms

of polyuria (frequent urination), polydipsia (increased thirst) andpolyphagia (increased hunger).

Is a group of metabolic diseases characterized by high blood sugar (glucose) levels that result from defects

ion, or action, or both. Diabetes mellitus, commonly referred to as diabetes (as it will be in this article) was first


9/17

identified as a disease associated with "sweet urine," and excessive muscle loss in the ancient world. Elevated

levels of blood glucose (hyperglycemia) lead to spillage of glucose into the urine, hence the term sweet urine.

Normally, blood glucose levels are tightly controlled by insulin, a hormone produced by the pancreas.

Insulin glucose level. When the blood glucose elevates (for example, after eating food), insulin is released from the

pancreas to normalize the glucose level. In patients with diabetes, the absence or insufficient production of insulin

causes hyperglycemia. Diabetes is a chronic medical condition, meaning that although it can be controlled, it lasts

a lifetime.

Signs and Symptoms of Pre-Diabetes

y Very often there are no signs or symptomsy It is often discovered during a routine physical with basic screening for fasting blood glucose levels.y Normal level below 100 mg/dly 100 to 125 mg/dl this indicates impaired fasting glucose or pre-diabetes.y Over 126 mg/dl most likely means a diagnosis ofType 2 diabetes

Criteria for Diagnosis of DM

y Symptoms of DM plus casual plasma glucose concentration > 200mg/dl (11.1 mmol/L)o Casualis defined as any time of day without regard to time since last meal.o The classic symptoms of DM include poyluria, polydipsia, and unexplained weight loss, or 3 Ps

y Fasting Plasma glucose of >126 mg/dl (7.0 mmol/L)o Fasting is defined as no caloric intake for at least eight hours oro Fasting blood glucose 10 12 hours NPO

y 2 hour post prandial glucose >200mg/dl during an OGTT.o OGTT should be performed as described by the WHO using glucose load containing the

equivalent of75g (non-pregnant) of anhydrous glucose dissolved in water.

o 100 g for pregnant womeno OGTTOral Glucose Tolerance Testo 140 199 mg/dl = pre-diabetic stageo Normal OGTT


10/17


11/17

THE PATHOPHYSIOLOGY OF DIABETES MELLITUS

Deficient insulin production

Hyperglycemia

Inc. concentration of blood glucose

Glucosuria

Excess glucose excreted in urine

Excess fluid loss

Polyuria / Polydipsia (thirst)

Insulin deficiency

Impaired metabolism of CHON and fats

Weight loss

Decreased storage of calories

Polyphagia (excessive eating

The first stage in type

2 diabetes is insulin

resistance!


12/17

Synthesis of the Disease

Signs and Symptoms

y Hyperglycemia failure to produce insulin and/or insulin resistance, glucose cannot be transported tocells due to inadequate insulin, glucose stays in the blood stream.

y Polyuria increased urine output due to ketone excretion and glucose in urine increases osmotic pressureleading to increased fluid loss.

y Polydipsia excessive thirst due to dehydration secondary to polyuria.y Polyphagia excessive hunger secondary to tissue breakdown and inability of cell to get glucose due to

inadequate insulin.

y Blurred/Loss of vision chronic exposure of ocular lens and retina to hyperosmolar fluidsy Weakness, fatigue and dizziness decreased plasma volume leads to postural hypotension and K loss and

protein catabolism contributes to weakness

y Glucosuria kidneys compensate to elevated blood glucose levels by excreting excess glucose in the uriney Weight loss due to wasting of lean body mass secondary to fat and protein metabolism.

Complications

Acute Complications

y Hyperglycemia glucose cannot be transported to cells because of lack of insulin.y Diabetic Ketoacidosis breakdown of fats produce ketones and ketones turn the blood acidic. Symptoms

include N/V and abdominal pain.

y Dehydration body excretes large amounts of urine to eliminate excessive glucose and ketones.y Electrolyte Imbalance osmotic diuresis lead to K excreted in urine: metabolic acidosis loses excessive

amounts ofNa, phosphate, Cl and bicarbonate in urine and vomitus.

y Hyperglycemic hyperosmolar nonketotic syndrome variant of diabetic ketoacidosis characterized byextreme hyperglycemia, profound DHN, mild or undetectable ketonuria and absence of acidosis. Osmosis

of water occurs from interstitial spaces and cells leading to increase in blood osmolality and osmotic

diuresis.

y Hypoglycemia a.k.a. insulin reaction or hypoglycemic reaction. It is due to excessive use of insulin andother glucose-lowering medications

Adrenergic Manifestations Neuroglycopenic manifestations


13/17

Chronic Complications

Macrovascular Complications

y Coronary Artery Diseases atypical or silent and they often present as indigestion, or unexplainedheart failure, dyspnea on exertion or epigastric pain. Coronary artery changes influence decreased

oxygen and nutrients to myocardium.

y Cerebrovascualr Diseases (atheroembolitic infraction) manifested by transient ischemic attack andCVAs. Increased prevalence of stroke in clients with DM may be related to the development of

diabetic neuropathy and resultant proteinuria, HPN and platelet adhesiveness.

y Hypertension a major risk factor for stroke and neuropathy.y Peripheral Vascular Disease associated with infection and trauma in lower extremities which could

lead to amputation.

y Infections infected areas heal slowly because the damaged vascular system cannot carry sufficientoxygen, WBCs, nutrients and antibodies to the injured site. UTI and Diabetic foot infection are the

common infections in DM.

Long-Term Complications of Diabetes

Tissue or Organ

Affected

What Happens Complications

Blood vessels Fatty material (atherosclerotic

plaque) builds up and blocks

large or medium-sized arteries

in the heart, brain, legs, and

penis. The walls of small blood

vessels are damaged so that thevessels do not transfer oxygen

to tissues normally, and the

vessels may leak.

Poor circulation causes wounds to

heal poorly and can lead to heart

disorders, strokes, gangrene of the

feet and hands, erectile dysfunction

(impotence), and infections.

Eyes The small blood vessels of the

retina are damaged.

Decreased vision and, ultimately,

blindness occur.

Kidney Blood vessels in the kidney

thicken.

Protein leaks into urine.

Blood is not filtered normally.

The kidneys malfunction, and

ultimately, kidney failure occurs.

Nerves Nerves are damaged because

glucose is not metabolized

normally and because the blood

supply is inadequate.

Legs suddenly or gradually weaken.

People have reduced sensation,

tingling, and pain in their hands and

feet.


14/17

DIAGNOSTIC EXAMS AND TEST FOR DIABETES MELLITUS

y Fasting Plasma Glucose Test (FPG) Confirmed by repeat testing on another day

When over symptoms of hyperglycemia (polyuria, polydipsia, and poylphagia) co-exist

Normal: 70 to 100 mg/dl

100 125 mg/dl pre-diabetic stage (check BS q 3 mos)

Glucose level exceeding 126mg/dl (7.0 mmol/L) Signals diabetes

DM: a 140mg/dl for 2 readings

y Random or casual Plasma Glucose Measurement Measurement exceeding 200mg/dl (11.1 mmol/L) plus manifestation of diabetes

Casual is defined as any time of day without regard to the time of the last meal.

y Two-Hour OGTT (Oral Glucose Tolerance Test) Non-pregnant = 75gms.

Test for 2 hours after glucose rich drink after FBS

Normal: less than 140 mg/dl

140 199 mg/dl pre-diabetic stage

200 mg/dl signals diabetes

Done in out-patient basis

Important: (no stress; regular diet)

1 hour, 2 hour, 3 hour OGTTo Done when results of FBS/2 hour PPBS are borderline (high normal)

y HgbA1c Glycohemoglobin or glycosylated hemoglobin Normal fasting blood sugar after 120 days; because sugar is attached to RBC

Most accurate Normal (7 and below)

Autonomic

nervous system

The nerves that control blood

pressure and digestive processes

are damaged.

Swings in blood pressure occur.

swallowing becomes difficult.

Digestive function is altered, and

sometimes bouts of diarrhea occur.

Erectile dysfunction develops.

Skin Blood flow to the skin is

reduced, and sensation is

decreased, resulting in repeated

injury.

Sores and deep infections (diabetic

ulcers) develop. Healing is poor.

Blood White blood cell function is

impaired.

People become more susceptible to

infections, especially of the urinary

tract and skin.

Connective

tissue

Glucose is not metabolized

normally, causing tissues to

thicken or contract.

Carpal tunnel syndrome and

Dupuytren's contracture develop.


15/17

Type I Diabetics will typically have hemoglobin A1C determined every 3 to 4months.

Type II Diabetics will often require measurements less often (twice a year)

o HgbA1Co Normal : less than 6.5 %o Excellent: 6.5 7.5 %o Good: 7.5 8.5 %o Fair: 8.5 9.5 %o Poor: Greater than 9.5 %

MEDICAL MANAGEMENT AND TREATMENT OF DIABETES MELLITUS

Treatment of diabetes involves diet, exercise, education, and, for most people, drugs. If people withdiabetes strictly control blood sugar levels, complications are less likely to develop. The goal of diabetes

treatment, therefore, is to keep blood sugar levels within the normal range as much as possible.

Treatment of high blood pressure and cholesterol levels can prevent some of the complications of

diabetes as well. A low dose of aspirin taken daily is also helpful.

People with diabetes benefit greatly from learning about the disorder, understanding how diet andexercise affect their blood sugar levels, and knowing how to avoid complications. A nurse trained in

diabetes education can provide information about managing diet, exercising, monitoring blood sugar

levels, and taking drugs.

People with diabetes should always carry or wear medical identification (such as a bracelet or tag) to alerthealth care practitioners to the presence of diabetes. This information allows health care practitioners to

start life-saving treatment quickly, especially in the case of injury or altered mental status. Diet

management is very important in people with both types of diabetes. Doctors recommend a healthy,

balanced diet and efforts to maintain a healthy weight. Some people benefit from meeting with a dietitian

to develop an optimal eating plan.

People with type 1 diabetes who are able to maintain a healthy weight may be able to avoid the need forlarge doses of insulin. People with type 2 diabetes may be able to avoid the need for all drugs by achieving

and maintaining a healthy weight. Some people who have been unsuccessful in losing weight through dietand exercise may take drugs to help them lose weight or may even undergo stomach reduction surgery.

In general, people with diabetes should not eat much sweet food. They should also try to eat meals on aregular schedule. Long periods between eating should be avoided. People with diabetes also tend to have

high levels of cholesterol in the blood, so limiting the amount of saturated fat in the diet is important.

Drugs may also be needed to help control the level of cholesterol in the blood.

Appropriate amounts of exercise can also help people control their weight and maintain blood sugarlevels within the normal range. Because blood sugar levels go down during exercise, people must be alert

for symptoms of low blood sugar. Some people need to eat a small amount of food with sugar during

prolonged exercise, decrease their insulin dose, or both. People with diabetes should stop smoking and

consume only moderate amounts of alcohol (up to one drink per day for women and two for men).

Diabetic ketoacidosis is a medical emergency, because it can cause coma and death. Hospitalization,usually in an intensive care unit, is necessary. Large amounts of fluids are given intravenously along with

electrolytes, such as sodium, potassium, chloride, and phosphate, to replace those fluids and electrolytes

lost through excessive urination. Insulin is generally given intravenously so that it works quickly and the

dose can be adjusted frequently. Blood levels of sugar, ketones, and electrolytes are measured every few

hours. Doctors also measure the blood's acid level. Sometimes, additional treatments are needed to

correct a high acid level. However, controlling the levels of sugar in the blood and replacing electrolytes

usually allow the body to restore the normal acid-base balance.


16/17

Nonketotic hyperglycemic-hyperosmolar coma is treated much like diabetic ketoacidosis. Fluids andelectrolytes must be replaced. The levels of sugar in the blood must be restored to normal levels gradually

to avoid sudden shifts of fluid into the brain. The blood sugar levels tend to be more easily controlled than

in diabetic ketoacidosis, and blood acidity problems are not severe.

Insulin ReplacementTherapy

People with type 1 diabetes almost always require insulin therapy, and many people with type 2 diabetes

require it as well. Insulin is injected. It currently cannot be taken by mouth because insulin is destroyed in the

stomach. A nasal spray form of insulin was available but has been discontinued. New forms of insulin, such as

forms that can be taken by mouth or applied to the skin, are being tested.

Insulin is injected under the skin into the fat layer, usually in the arm, thigh, or abdominal wall. Small

syringes with very thin needles make the injections nearly painless. An air pump device that blows

the insulin under the skin can be used for people who cannot tolerate needles. An insulin pen, which contains a

cartridge that holds the insulin, is a convenient way for many people to carry insulin, especially for people who

take several injections a day outside the home. Another device is aninsulin pump, which

pumps insulin continuously from a reservoir through a small needle left in the skin. Additional doses of insulin can

be released at programmed times, or release can be triggered as needed. The pump more closely mimics the way

the body normally produces insulin. For some people, the pump offers an added degree of control, whereas othersfind wearing the pump annoying or develop sores at the needle site.

Insulin is available in three basic forms, divided by speed of onset and duration of action:

y Rapid-acting insulin, such as regular insulin is fast and short acting. Regularinsulin reaches its maximumactivity in 2 to 4 hours and works for 6 to 8 hours. Lispro, aspart, and glulisine insulins, special types of

regular insulin, are the fastest of all, reaching maximum activity in about 1 hour and working for 3 to 5 hours.

Rapid-acting insulin is often used by people who take several daily injections and is injected 15 to 20 minutes

before meals or just after eating.

y Intermediate-acting insulin (such as insulin zinc suspension, lente, or isophaneinsulin suspension) startsto work in 1 to 3 hours, reaches its maximum activity in 6 to 10 hours, and works for 18 to 26 hours. This type

of insulin may be used in the morning to provide coverage for the first part of the day or in the evening to

provide coverage during the night.

y Long-acting insulin (such as extended insulin zinc suspension, ultra-lente, or glargine) has very little effectin the first few hours but provides coverage for 20 to 36 hours depending on which of these types is used.

Insulin preparations are stable at room temperature for months, allowing them to be carried, brought to work, or

taken on a trip. Insulin should not, however, be exposed to extreme temperatures. The choice of insulin is

complex. The following factors are considered before deciding which insulin is best:

How willing and able people are to monitor their blood sugar levels and adjust the insulin dosage How varied daily activity is How adept people are at learning about and understanding the disorder How stable blood sugar levels are during the day and from day to dayThe easiest regimen to follow is a single daily injection of an intermediate-acting insulin. However, such a

regimen provides the least control over blood sugar levels and is, therefore, rarely the best approach. Stricter

control may be achieved by combining two insulinsa rapid-acting and an intermediate-acting insulin in one

morning dose. This combination requires more skill, but it offers people greater opportunity to adjust the blood

sugar levels. A second injection of one insulin or both may be taken at dinner or at bedtime. Strictest control is

usually achieved by injecting a rapid-acting and an intermediate-acting insulin in the morning and evening along

with several additional injections of rapid-acting insulin during the day. Adjustments can be made as insulin needs


17/17

change. Measuring blood sugar levels at various times during the day helps determine the adjustment. Although

this regimen requires the most knowledge of the disorder and attention to the details of treatment, it is

considered the best option for most people who are treated with insulin, especially people with type 1 diabetes.

Some people, especially older people, take the same amount of insulin every day. Other people adjust the insulin

dose daily depending on their diet, exercise, and blood sugar patterns. In addition, insulin needs may change if

people gain or lose weight or experience emotional stress or illness, especially infection.

Monitoring Treatment

Monitoring blood sugar levels is an essential part of diabetes care. People with diabetes must adjust their

diet, exercise, and take drugs to control blood sugar levels. Monitoring blood sugar levels provides the information

needed to make those adjustments. Waiting until symptoms of low or high blood sugar levels develop is a recipe

for disaster.

Many things cause blood sugar levels to change:

Diet Exercise Stress Illness Drug Time of dayThe blood sugar levels may jump after people eat foods they did not realize were high in carbohydrates.

Exercise may cause the levels of sugar in the blood to fall low, requiring that additional sugar be eaten. Emotional

stress, an infection, and many drugs tend to increase blood sugar levels. Blood sugar levels increase in many

people in the early morning hours because of the normal release of hormones (growth hormone and

corticosteroids), a reaction called the dawn phenomenon. And blood sugar may shoot too high if the body releases

sugar in response to low blood sugar levels (Somogyi effect).

Blood sugar levels can be measured easily at home or anywhere. Most blood sugar monitoring devices use a

drop of blood obtained by pricking the tip of the finger with a small lancet. The lancet holds a tiny needle that can

be jabbed into the finger or placed in a spring-loaded device that easily and quickly pierces the skin. Most people

find the pricking nearly painless. Then, a drop of blood is placed on a reagent strip. In response to sugar, thereagent strip undergoes some chemical changes. A machine reads the changes in the test strip and reports the

result on a digital display. Most of these machines time the reaction and read the result automatically. Some

devices allow the blood sample to be obtained from other sites, such as the palm, forearm, upper arm, thigh, or

calf. The machines are smaller than a deck of cards.

A newer device reads blood sugar through the skin without needing a sample of blood. The device is worn like

a wristwatch and can measure the level of sugar in the blood every 15 minutes. Alarms on the device can be set to

sound when blood sugar levels drop too low or climb too high. Disadvantages of this device are that it must be

calibrated periodically with a blood test, it may irritate the skin, and it is somewhat large. Other devices can

monitor glucose continuously. However, these devices are not routinely used, as they are expensive and have not

been shown to be better than glucose meters. In certain circumstances, these devices are less reliable, such as in

severe hypoglycemia.

Anatomy and Physiolog2

Documents

Transcript of Anatomy and Physiolog2