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Complications of Diabetes

Diabetes has been described, and aptly so, as a disease of complications. The complications of diabetes are more agonising and torturing than the disease itself. Acute complications can arise at any time during the course of the disease, whereas the more dreaded chronic complications slowly unfold themselves years after the onset of diabetes. Many a time, a presenting complication leads to the diagnosis of the disease. Zealous control of diabetes does help in warding off its acute complications; but whether it delays or mitigates the chronic complications or not is a controversial issue. That is the reason why prevention of diabetes assumes special importance.

Acute Complications of Diabetes:

(1) Diabetic Coma (Unconsciousness): Diabetic coma is commonly seen in juvenile (child or young) diabetics but is uncommon in persons suffering from maturity onset diabetes.

Before the discovery of insulin, more than half of juvenile diabetics died of diabetic coma. Today, however, the mortality rate due to this complication has been brought down to 1 -2 %, thanks to effective treatment with insulin.

This type of unconciousness ensues when the concentration of glucose in the blood rises much above normal, a condition called hyperglycemia. The disintegration of stored fat inside the body is commensurate with the amount of glucose in blood. The end-products of fat­disintegration are ketone bodies, which due to their acidic nature, render the blood acidic. The body tries to get rid of these harmful ketone bodies by producing more and more urine. This, however, results into a reduction in the fluid content of the blood, thereby increasing the concentration of ketone bodies. Thus a vicious circle sets in. This acidified blood untowardly affects the brain to give rise, first to drowsiness and lethargy and then gradually to diabetic coma.

The probable causes for the rise of glucose in blood are:

  1. Undetected or untreated diabetes.
  2. Consumption of carbohydrate-containing refined foods, especially sugar.
  3. Inadequacy or total lack of external (medicinal) insulin.
  4. Development of resistance inside the body to  medicinal insulin.
  5. A decrease in the effectiveness of medicinal insulin due to some other infection or disease.
  6. A stressful physical condition like surgery or pregnancy.

It should be borne in mind that a diabetic may become unconcious even when the concentration of glucose in the blood drops much below normal (a condition called hypoglycemia). However, such unconciousness ensues rapidly. On the other hand, unconsciousness due to excessive glucose and ketosis is a slowly developing condition. Hours or days before its advent, a patient experiences symptoms like dryness of mouth, acute thirst, profuse urination, headaches, nausea vomitting, abdominal pain, weakness, laboured breathing, irrelevant answers to questions and drowsiness. Of these symptoms nausea-vomitting, drowsiness and irrelevant answers to asked questions are probably the most common. If the seriousness of the situation is not realised and the patient not treated promptly, he gradually becomes unconscious. However, in some child diabetics, hyperglycemic coma has been seen to set in very fast, i.e., in 12 to 24 hours.

Diabetic coma is a medical emergency and calls for urgent, expert treatment. The patient should be immediately hospitalised so that he can be given insulin, fluids and salts like potassium through a vein and be constantly monitored.

In fact, hyperglycemic coma should not in the first place be allowed to occur. Its prevention is relatively easy provided ­

  1. The patient has adequate knowledge of the disease and its treatment,
  2. The concentration of glucose in blood is not allowed to rise by fastidiously adhering to correct, timely diet and medicines,
  3. The dosage of insulin is maintained (not altered) even if food is not taken in other illnesses,
  4. Even the most initial warning signs and symptoms of hyperglycemia, described above, are immediately heeded 10 and necessary steps are taken.

A diabetic who experiences one or more of the above symptoms should take complete rest, have a lot of fluids and examine his own urine 3-4 times a day for presence of sugar and acetone. If acetone is detected in urine, he should immediately call for his doctor, and should increase the dosage of insulin/oral medicines as per the doctor's advice.

It is desirable for every diabetic to keep in his pocket an identification card, which besides mentioning that he is a diabetic, bears his and his doctor's name and address and the type of antidiabetic treatment he is undergoing. This will prevent many mishaps to which a diabetic is liable.

(2) Boils and carbuncles : Recurrent boils and carbuncles may, in fact, be the first indication of diabetes. The factors responsible for this complication are: (a) high glucose-level in the blood vessels of the skin and (b) poor resistance-power against pus-forming micro­organisms.

(3) Acute gangrene : Gangrene is defined as the death of a mass of tissue or an organ. Gangrene of a toe or a foot is 50 to 60 times more common in diabetics than in healthy persons. Without adequate care, even a trivial injury to a toe or foot may terminate into gangrene.

Narrowing of the blood-vessels, poor resistance power and untoward changes of the nervous system are said to be responsible for such proneness of diabetics to gangrene. Gangrene usually necessitates amputation of the affected part, to keep the patient alive. Before the advent of insulin, 50 % of the diabetics would have died if gangrene supervened. But today, thanks to insulin, antibiotics and medical care, this mortality rate has fallen below 7 % and amputations are on the wane.

Chronic or late complications of diabetes:

(1) Complications of the nervous system (diabetic neuropathy) : Almost 90 percent of diabetics suffer from one or the other complication of the nervous system. However, only 25 to 50 percent of them have to face serious complications. The most common complications of the nervous system are derangements of the touch sensation. Sometimes the touch sensation becomes abnormally acute (hyper­esthesia). The patient experiences a burning sensation in his limbs. He is more troubled during the night, when he cannot even tolerate a light covering and remains awake. At other times the touch sensation is dulled so that the patient experiences numbness in his limbs.

Undesirable effects on the autonomous nervous system bring about a decrease in the efficiency of the urinary bladder. This either leads to incomplete emptying of the bladder bladder or uncontrollable dribbling (incontinence) of urine. When the bladder cannot be emptied completely, the retained or residual urine harbours disease causing bacteria, which leads to the inflammation of theurinary bladder (cystitis).

(2) Complications of the excretory system (diabetic nephropathy) : Five years or more after the onset of diabetes, kidneys start getting harmed. About 15 percent of diabetics succumb to some renal complication or renal failure. Diabetes gives rise to hardening of the glomeruli, the filtering units of kidneys. This condition is known as 'glomerulosclerosis'. Besides, the blood vessels of kidneys also become hard and narrow. This leads initially to loss of proteins in the urine and then gradually to a rise in blood pressure, a swelling all over the body and kidney failure. When kidney failure ensues, serum urea and serum creatinine levels begin to rise, nausea and vomitting occurs and the patient gradually loses consciousness. The condition is usually climaxed by a total loss of consciousness (called uremic coma) which usually proves irreversible and fatal.

Diabetics more commonly suffer from an inflammation of the kidneys, called pyelonephritis.

(3) Complications of the cardiovascular system : Diabetes speeds up the process of atherosclerosis, i.e., the degeneration of the blood vessels. In diabetics, the inner surface of blood vessels gets deposited not only with cholesterol but also with calcium. Consequently, flexible and elastic bloodvessels are transformed into hard and narrow pipes. Due to narrowing of blood vessels, various organs of the body and the limbs do not get adequate nourishment. That is the reason why even after a short walk, a diabetic experiences pain in his calf muscles.

A disorder of the blood vessels of the limbs, called peripheral arterial disease, is more common in diabetics. If this disease advances too much, it may terminate in gangrene.

Due to hardening of blood vessels (atherosclerosis), the incidence of high blood pressure is very high in diabetics. Albeit, high blood pressure may also be a result of some renal complication.

Disorders of coronary arteries are found to be more common and more severe in diabetics. Mortality rate due to coronary artery disease is two times higher in diabetics as compared to healthy persons.

When coronary arteries become narrow, the heart cannot obtain adequate nourishment. This leads to chest pain-angina pectoris. Complete obstruction of a coronary artery gives rise to a heart attack. The incidence of heart attacks is 3 to 6 times higher in diabetics as compared to healthy persons. Healthy women are usually immune to coronary heart disease. But incidence of heart disease in diabetic women rises to a level equal to that in men. After a heart attack, the chances for a diabetic to live for 5 more years are slim. In fact, many a diabetic succumb to the first heart attack.

Degenerative changes in the arteries of a diabetic make him prone to cerebral haemorrhage. Cerebral haemorrhage may result into paralysis or even death.

(4) Complications of the eye and the retina (diabetic retinopathy) : Diabetic retinopathy is the third chief cause of blindness. In developing countries, cataract and deficiency of Vitamin A are more important causes for blindness. But in America, every sixth blind person is a victim of diabetic retinopathy.

Diabetes chiefly affects the small blood vessels (capillaries) of the retina. Capillaries get abnormally dilated at some places and obstructed at other places. Degenerative changes occur in the cells of the retina. Besides, new, defective capillaries rapidly grow into the retina. All these changes lead to a gradual diminution of vision.

With the progress in degenerative changes, capillaries become thinner and thinner at the sites of dilatation and may rupture, leading to retinal or vitreous haemorrhage.

Excessive bleeding into the retina may lead to detachment of the retina and cause sudden loss of vision.

The crystalline lens of the eye depends for its nourishment on the glucose dissolved in the aqueous humour (a dynamic fluid present inside the eye). Due to wide fluctuations in the amount of glucose in the blood and consequently that in the aqueous humour, the nutrition of the lens is thrown into disarray. This leads to a loss in transparency of the lens. This is nothing but cataract. Diabetic cataract occurs very early in a patient's life and progresses rapidly.

Due to neo-vascularisation, the circulation of the fluid of the eye is jeopardised. This leads to an increase in the pressure inside the eyeball, a dreadful condition called glaucoma. Glaucoma, if not adequately controlled, leads to gradual blindness.

(5) Complications of the reproductive system : A diabetic woman has to face many problems during pregnancy. Diabetes creates risks to the life of the mother as well as the foetus.

About 25 percent of pregnant diabetic women fall a victim to a dreadful condition called toxaemia of pregnancy. Toxaemia usually terminates into a miscarriage. Diabetic women more often give birth to dead babies or babies with congenital defects.

Diabetic women develop very large babies in their wombs. This causes great difficulty during the delivery and both the mother as well as the baby have to face risks of an injury during delivery.

Diabetes throws the marital life of its victim into complete disarray. Diabetic women frequently suffer from frigidity and diabetic men from sexual weakness or impotence. Disorders of autonomous nervous system, too, are partly responsible for this trouble.

(6) Complications of the respiratory system : Diabetic persons easily contract infections of the respiratory tract.

About 15 percent of patients suffering from tuberculosis are found to have diabetes. Tuberculosis and diabetes undesirably affect each other to give rise to a vicious circle of complications. Many a time, a diabetic person contracts tuberculosis after falling a prey to diabetic coma.

Pus-filled cavities (abscesses) are formed more often in lungs of diabetics.

(7) Complications of the digestive system: Diabetics have to face many disorders of the digestive system.

Diabetics often suffer from nausea and vomitting.

Nocturnal diarrhoea is also their common complaint.

About 25 per cent of child diabetics suffer frOlIl enlargement of the liver.

Gall stones are more common in diabetics. The mortality rate due to acute diseases of the gall-bladder is five times higher in diabetics than in others.

Diabetic coma arising due to defective metabolism of the dietary fats has been described earlier.

(8) Complications of the feet : Corns, nail infections, athlete's foot (infection of the skin between the toes), etc., are much more common in diabetics. A high blood-glucose level, a diminution in the blood-supply due to narrowing of blood vessels and disorders of the nervous system are the factors responsible for complications of the feet.

In diabetes, even a trivial foot injury may get transformed into dreadful gangrene, which may necessitate amputation of the affected toe or the foot.

(9) Other complications and infections : Diabetics easily contract skin diseases like erythrasma and moniliasis. Diabetes is sometimes suspected or detected after a person complains of infections of nails, corners of the mouth or the vagina.

Xanthoma diabeticorum is another disorder commonly seen in diabetics. This disease is characterised by raised red-yellow spots on palms, soles, knees or buttocks.

Pruritis valvae, a vaginal skin-disease causing intense itching is commonly seen in diabetic women.

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