Peptic Ulcer and Its Treatment

What is Ulcer?

Ulcer is the inflammation and lesion of skin and mucous membrane of various organs of our body. Ulcer is a result of tissue necrosis or cell death. 

 

 What is Peptic Ulcer?

Peptic ulcer refers to duodenal and stomach ulcer. When we take any food it has to pass through esophagus to stomach and then from stomach to the small intestine. Our small intestine is divided into three parts namely duodenum, jejunum, and ileum. As duodenum lies at the close proximity to the stomach, it is prone to ulcer like stomach. 

How Do You Know You Have Ulcer?

You you have peptic ulcer, whether duodenal or stomach ulcer, you will feel stomach discomfort it not pain. There will also gas formation. In stomach ulcer, discomfort increases with consumption of foods but in duodenal ulcer, if you ingest any food, your discomfort will go away. In gastric ulcer, you will loose weight, but in duodenal ulcer you gain weight due to excessive food consumption to relieve from stomach discomfort.

How You Will Confirm You Have Ulcer?

The signs and symptoms of ulcers can be also due to temporary gastric acid formation or gas formation. You will not know for sure unless you go through the confirmatory test of ulcer. So far, the most effective confirmatory test for peptic ulcer is endoscopy. By endoscopy, damage of tissue of the gut and duodenal part of small intestine can be detected. All the tissue erosions can be visualized. 

How Will You Treat Ulcer?

It is recommended that you consult a physician who is specialized in gastroenterology. He might prescribe you some medicines or antiulcerant agents. You might be also asked to change your food habit. To get rid of ulcer, it is recommended to take foods with regular intervals. You should not be in empty stomach for a long time. There are mainly three groups of drugs that are prescribed to a ulcer patient. These drugs are:

a) Antacids: Antacids are frequently used anti-ulcer drugs. Antacids are basic drugs and used to neutralize the acidic environment of the stomach. The typical antacids used are Magnesium Oxide, Aluminium Oxide, Simethicone etc. Magnesium Oxide is laxative in nature and Aluminium Oxide is constipative. So, they are often used together in antacid suspensions or tablets.

b) H2 receptor blocker: There are H2 histamine receptors in stomach. They binds with endogenous histamine which is produced in our body and is associated with gastric acid secretion. H2 receptor blockers block these histamine receptors and prevent acid secretion to some extent. 

c) Proton Pump Inhibitor: Proton pump inhibitors are most effective in the treatment of ulcer. It stops acid secretion completely and irreversibly. Proton pump inhibitors should be used in severe cases.

Helicobacter pylori Eradication

Helicobacter pylori is a bacteria present in the stomach and responsible for gastric acid formation. Our stomach is protected by a mucosa membrane barrier which protect it from self digestion by hydrochloric acid. Helibacter pylori uses this stomach barrier for its own protection against gastric acid environment and damages the stomach tissue. If this is the reason for stomach ulcer, Helicobacter pylori eradication procedure can result in to permanent relief from peptic ulcer disease.

Insulin in the treatment of Diabetes

Introduction

Insulin therapy is must in type 1 patients who are insulin dependent. Their body is unable to produce any insulin due to destruction of pancreatic beta cells. So type 1 patients are treated with insulin injection in a regular interval basis. However, even type 2 diabetic patients may require insulin injection in two cases:

1. Excessively increased  blood sugar level
2. Defective insulin production and secretion

 Source of Insulin

There are mainly three sources of insulin that is administered to a diabetic patient. These sources are: 

1. Human Insulin : Human insulin is best insulin to be administered in a human being. This insulin is taken from a normal healthy person and administered to a diabetic patient. Human insulin is expensive because everybody needs insulin for their own.
2. Bovine insulin : Not as good quality insulin as human insulin but easily available and inexpensive. This insulin is used by mass population below poverty level.
3. Bacteria produced insulin: This type of insulin is produced genetically by recombinant DNA technology from a bacteria. This is a good source of insulin now and may be will be the number one source of insulin in near future. 

 Types of insulin according to duration of action 

 According to duration of action, there are two types of insulin:

1. Short Acting Insulin : This insulin acts shortly and should be given with a regular short interval

1. Long Acting Insulin : Duration of this insulin is comparatively  long. So it is administered once or twice a day.

Route of Insulin Administration

Subcutaneous route or 'under the skin' route has been proven as the most convenient route of insulin administration. Insulin injection by any other route such as intravenous, or intramuscular or oral route result in wastage or deactivation of insulin.

See this video to learn more about insulin administration in the treatment of diabetes:

Diabetes Medicines and Treatment

Intrudoction

The goal of diabetes treatment is to maintain as much normoglycemia as possible. Normoglycemia refers to normal blood sugar level of our body.  There are three approaches for diabetes therapy. They are, according to importance, 

1. Diet
2. Oral hypoglycemic agents
3. Insulin

Diet is the first line of choice of treatment in diebetes patients. Those who have mild diabetes, their diabetes can be managed simply by a well balanced diet. In moderate. In moderate to severe cases, blood glucose lowering agents (Oral hypoglycemic agents) and insulin is required but diet is maintained all the time. Diabetes diet should always contain low carbohydrate sugar and fat content. There should be plenty of fruits and vegetables. 

 Oral Hypoglycemic Agents

1) Sulphonylurea  (insulin secretagogue* ): 

  a)First generation : Acetohexamide, Chlorpropamide, Tolazamide, Tolbutamide,
  b)Second generation: Glibenclamide, Gliclazide, Glimepiride, Glipizide, Blyburide, Gilyquidone

2)Biguanides : Metformin, Phenformin, Buformin
    Indication: They are the most widely used medicines to treat type 2 diabetes.

Drugs for Diabetic Peripheral Neuropathy

1)alpha glucosidase inhibitors: Acarbose:
     Indication: It is indicated as an adjunct to lower blood glucose in patients with Type 2 diabetes,
     whose hyperglycemia cannot be managed on diet alone. 
     

2)Thiazolidinediones  (insulin sensitizers*) : Troglitazone, Pioglitazone, Rosiglitazone

3) Meglitinides (insulin secretagogue) : Rapaglinide, Nateglinide

    Indication: It is indicated as an adjunct to lower blood glucose in patients with Type 2

    diabetes, whose hyperglycemia cannot be managed on diet alone; same as the indication of 

    acarbose            

Insulin and Its Preparations

Insulin is injected subcutaneously in type 1 diabetic patients and in type 2 diabetic patients if the blood sugar level goes too high. There are three types of insulin preparation in diabetic patients:

• Short acting insulin

• Medium acting insulin

• Long acting insulin

 Other Drugs in Pipeline:  

1)GLP-1 or glucagon like peptide 1 and analogues,

2)GIP or gastric inhibitory polypeptide and Amylin.
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*insulin secretagogue : Promotes or facilitate insulin secretion from pancreas

*insulin sensitiszers : increase the action of insulin on its receptor

Diabetes Complications

Diabetes is a complex heterogeneous disease where multiple levels of abnormalities are present in various tissues. Defects of diabetes mellitus include short term  complications and long term damage, dysfunction and failure of various organs of our body. Short term complications and long term complications are also known as acute and chronic complications. 

Diabetic is closely associated with many other diseases like high blood pressure, kidney failure, skin diseases etc. So there are very large number of diabetes complications. Some are major complications and some are minor. We can remember all these complications easily with the help of a flow chart:

Diabetes Complications 

Major Complications:

Hypoglycemia : Hypoglycemia is a condition when a patient has low blood sugar level. Though diabetic patients have high blood sugar level, hypoglycemia can occur due to overdose of anti-diabetic drug and injection of insulin. Excess blood sugar is harmful for our body but to maintain normal body function, moderate level of blood sugar should be maintained. If blood sugar is increased, there is no chance of immediate harm, but decreased blood sugar or hypoglycemia can be harmful. It's because our brains feed on glucose and nothing else. So, if blood sugar or glucose level is lowered significantly, brain does not get any food and it leads to loss of consciousness and amnesia. It is more common in type 1 diabetes due to injection of insulin. Insulin can lower blood glucose level very fast.

Hyperglycemia : It is opposite to hypoglycemia and defined by high blood sugar level. It is a more common occurrence in type 2 diabetes patient than type 1 patient. Hyperglycemia can give rise to blood sugar level as high as 15 mmol per liter which is very high compared to normal blood sugar level which is below 6 mmol per liter. Hyperglycemia has no short term complication but if it persists log longer period of time it can increase the viscosity of blood and can damage the blood vessels. Also hyperglycemia can lead to high blood pressure. 

Diabetic ketoacidosis : Ketosis of ketoacidosis is a condition where there is excess ketone body present in blood and urine. Excess ketone bodies in blood is called ketonemia and excess ketone bodies in urine is called ketonuria. Ketone bodies are break down products of body fats. Diabetic keto acidosis occurs if the patient is deprived of hydration and food consumption. To meet the body's energy needs, body fats are then utilized. Fats of fatty acids go through oxidation process to yield energy. Ketone bodies are the byproduct of this reaction. Two main ketone bodies produced are  acetoacetate and beta hydroxybutyrate . The condition is called ketoacidosis or ketosis becasue ketone bodies contain acidic ketone group and acidic in nature. Some times diabetic ketoacisosis can be life threatening.

Diabetic Coma : Diabetic coma is a emergency situation that can result from untreated diabetes mellitus. Main causes are severe hypoglycemia and prolonged ketoacidosis.

Diabetic Retinopathy : Retinopathy is a disease of the retina that can result in loss of vision.  Diabetic retinopathy is leading cause of blindness of working age adults.

Diabetic Nephropathy: Nephropathy is a disease of nephrons affecting the kidney. Diabetic nephropathy is the leading cause of end stage renal disease. 

Diabetic Neuropathy: Neuropathy refers to any pathology of peripheral nerves. It is a leading cause of non traumatic lower extremity amputations or surgical removal. 

                                                   Figure: Diatetic Neuropathy

                                           

Stroke: Stroke is a sudden loss of consciousness resulting when the rupture or occlusion of a blood vessel leads to oxygen lack in the brain. Long term diabetes patients have 1.2 to 1.8 fold increased risk of stroke.

Minor Complications:

1) Foot ulcer

2) Reduce resistance to infection

3) Skin rash and skin disease

4) Weakness of bones and teeth

5)  Excess sweating

 

Diabetes Classification : Types of Diabetes

Classification of Diabetes Mellitus

Diabetes Mellitus can be classified into mainly two types:

1)Type 1 Diabetes Mellitus (IDDM)

2)Type 2 Diabetes Mellitus (NIDDM)

IDDM and NIDDM classification is the old classification system of diabetes. IDDM stands for Insulin Dependent Diabetes Mellitus and NIDDM stands for Non Insuline Dependent Diabetes Mellitus.

Old classification system is not used because even type 2 diabetes patients can be insuline dependent if blood sugar level goes too high. So insuline dependency is not a convenient factor to classify diabetic patients. That is why, this is classified by the causative factors of diabetes and named type 1 and type 2. Type 1 diabetes is also known as juvenile onset diabetes according to its common target age group.

Type 1 diabetes : Type 1 diabetes is defined by an absolute requirement of exogenous insulin results from the autoimmune destruction of insuline - secreting pancreatic B cells. Type 1 diabetes is prone to ketoacidosis and exogenous insulin is required to prevent ketosis.

            Causes: 1) Environmental factors : Virus and food habit
                         2) HLA Antigen* (Human Leukocyte Antigen)

Both of these causes leads to autoimmune destruction* of Beta cell of pancreas that produce insuline.

Type 2 Diabetes : Type 2 diabetes is characterized by a relative insulin deficiency due to insulin secretory defect with insulin resistance. Ketoacidosis is absent. Most diabetic patient in the world has type 2 Diabetes.

             Cause: 1) Obesity or excess weight
                         2)Insuline resistance : Insuline is produced but not utilized
                         3) Genetic factors : Family history of diabetes

Comparison / Differences Between Type 1 and Type 2 Diabetes

 

Features	Type 1 Diabetes	Type 2 Dabetes
Dependency	Insuline dependent	Non insuline dependent or insulin independent.
Synonyms	Insuline dependent diabetes mellitus (IDDM) or, Juvenile onset diabetes	NIDDM (Non Insuline Dependent Diabetes Mellitus)
Target age group	Children or teenagers	Adults
Age of Onset	Usually below 20 years	Usually above 40 years
Insulin production	Body produces very little to no insulin.	Body produces little insulin or insulin is produced but it’s not utilized.
Role of genetic factor	May or may not responsible to cause type 1 diabetes	Definitely responsible for type 1 diabetes
Autoimmune B cell destruction	Present	Absent
Weight	Normal weight or non-obese	Usually excess weight or obese
Ketosis or Diabetic Ketoacidosis	Common	Rare
Plasma glucose level	High	Mild to moderate
Islet cell mass of pancreas	Severely reduced	Moderately reduced
Autoantibodies	Present	Absent
Family history of diabetes	Uncommon	Common
Occurrence	Rare. Only 5 to 10 % of the diabetic patient worldwide	90 to 95 % diabetic patients have type 2 diabetes
Treatment Plan	Sugar controlled healthy diet and regular insulin injection	Diet & blood glucose lowering drugs. Insuline injection in severe case only.

Other types of diabetes : (less common)

MODY : Mody or Maturity Onset Diabetes of the Young is caused by mutation in a specific gene called autosomal dominant gene. It causes to produce defective insuline. MODY is inherited from any of the parents. MODY differs from type 2 diabetes on the basis that, type 2 diabetes is associated with multiple gene defects and MODY is related to only one gene mutation. 

GDM or Gestational diabetes mellitus: Gestational diabetes causes to women during pregnancy with previous history of diabetes diagnosis. Insuline receptors do not function properly in gestational diabetes due to interference of pregnancy related factors such as human placental lactagen with insuline receptors. It generally occurs during third trimester of pregnancy. It is well established  that whether it is a natural phenomenon or a disease because up to 15% pregnant woman suffer from gestational diabetes. Sometimes gestational diabetes can lead to type 2 diabetes if this condition persists after pregnancy.

Idiopathic diabetes : Idiopathic diabetes is closely related to type 1 diabetes. Type 1 diabetes is caused by autoimmune destruction of pancreatic beta cells but idiopathic diabetes has no known cause. It shows symptoms like diabetic ketoacidosis which is common in type 1 diabetes but there is no solid evidence of autoimmune cell destruction. Idiopathic diabetes can be both insuline dependent and insuline independent. 

LADA or Late Autoimmune Diabetes for Adults: Lada is a type of diabetes that has similarity with both type 1 and type 2 diabetes. The cause of this type of diabetes is autoimmunity like type 1 diabetes and it is diagnosed at adult age like type 2 diabetes. For similarity of both type of diabetes, it is known as type 1.5 diabetes. It is often misdiagnosed as type 2 diabetes. 

Diabetes incipidus : Diabates incipidus is not associated with glucose metabolism or insuline. It is a condition caused by lack of vasopressin or anti diuretic hormone (ADH) by posterior pituitary gland. It may also caused by defect in the nephrons of the kidneys where receptors of this hormone are present. Due to lack of anti diuretic hormone action , diuresis or urination occurs more frequently which is the only similarity of diabetes incipidus with diabetes mellitus.


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*HLA antigen : Consists of large number of genes related to human body's immune system.


*Autoimmune destruction : Pathogens (bacteria, virus) or external body compounds are destroyed by our body's immune system. But sometimes specific cells of our body organs are destroyed by our  immune system due to some disorder. This self destruction of body cells by our own immune system is referred to as autoimmune destruction.

Diabetes Basic Concepts

What is Diabetes?

Definition of diabetes: 'Diabetes is a heterogeneous group of metabolic disorders characterized by hyperglycemia resulting from defects in insuline secretion, insuilne action or both.'

                                                                  

                                                                (Definition from american diabetes association 2001)

Why it is metabolic disorder

Diabetes is associated with metabolic disorders. With that said, the question arises, how is this related metabolic disorders and which metabolism is impaired in this disease? Metabolic disorders are characterized by any impairment in metabolism or faulty or insufficient metabolism. Metabolism is the process how are body nutrients (carbohydrate, protein, fats, vitamins & minerals) are utilized. For example, to get energy from carbohydrate, it has to be metabolized first. At a certain point of metabolism, carbohydrates are broken down to from hexose monosaccharides like glucose, fructose, galactose etc. Glucose is the primary yield. To go through the further process of metabolism, the glucose has to be utilized. It has to enter the cell. The entrance of glucose is aided by insuline, a metabolic hormone which is deficit in diabetic patients. All diabetic patient has insuline deficiency. Insuline deficiency occurs for many reasons. What ever the reason is, this results in diabetes. Insuline can not help glucose to enter the cell and continue metabolism. Blood sugar  level is increased. So whatever food yields glucose at certain point of its metabolism, it will lead to high blood sugar level in diabetic patients.

How Do You Know You Have Diabetes 

Without testing blood sugar level, It is not possible to say for sure if someone has diabetes. But there are some common characteristics of diabetes by which one can make an assumption that he or she might have diabetes. The first symptom is frequent or excessive urination or polyurea. Other symptoms associated with diabetes mellitus are:

1)Polydipsia : Excessive thirst and dry mouth

2) Polyuria : Excessive and frequent urination

3) Polyphagia : Excessive hunger, increased appetite and increased food consumption

4) Change in weight : Recent weight gain

5) Blurring of vision : Caused by defects in retina

6) Nausea : Stomach discomfort and urge to vomit

7) Headache : Mild to moderate headache

What Causes Diabetes?

The cause of diabetes can be easily showed with a flow chart:

Diabetes Type

Type 1 or insuline dependent diabetes mellitus: Insuline secreting beta cells of pancreas are destroyed due to some reasons such as genetic and malignancy. Must take insuline in a regular interval.

Type 2  or non insuline dependent diabetes mellitus : Insuline secretion is impaired but  not totally destroyed. Also, insuline secretion may be normal but non responsive. Type 2 patients do not need to take exogenous  insuline unless their blood sugar level goes very high. Majority of diabetes patients have Type 2 diabetes.

Other Types: 

MODY : MODY is Maturity Onset Diabetes of the Young.

Gestational Diabetes : Women suffer from this diabetes during pregnancy

There are another type of diabetes called diabetes incipidus but that is not a sub-class of diabetes mellitus and nothing to do with insuline and glucose metabolism.

Who Are Prone To Diabetes

1. Those who have many diabetic patients in their family or blood line
2. Those who  do not do much physical exercise and work
3. Those who suffered from Pancreas beta cell destruction 
4. Whose parents are both diabetic
5. Those with habit of excessive eating especially carbohydrates and fats

Why Diabetes is called Diabetes Mellitus

Diabetic patients have high blood sugar. So their urine becomes concentrated. The word 'Mellitus' is derived from Latin, meaning honey. Diabetes came to known as diabetes mellitus due to honey like concentration of urine.

Diabetes Mellitus Concept Map Video:

Common Terminology and Parameters Related To Diabetes

Blood Sugar : Blood sugar is the concentration of sugar in blood. Here, sugar does not refer to sucrose or table sugar. Normal Sugar is a disaccharide. All carbohydrates, disaccharides and polysaccharides break down to glucose which mixes with blood. So blood sugar means blood glucose level.

Hyperglycemia: High blood sugar level in diabetic patients

Normoglycemia : Normal blood sugar level in human beings

Hypoglycemia : Abnormally low blood sugar level in a person

Glycemic Index: Glycemic Index is the measurement of effects of carbohydrate containing foods on blood sugar or blood glucose level. It is a relative parameter and compared with the glycemic index of glucose which is 100. Foods with high glycemic index leads to high blood sugar.

BMI: BMI means Body Mass Index. It is a parameter that measures compares body weight to body height and surface area. It's an important to determine diet of a diabetic patient. Normally, diabetic patients have BMI above normal.

Fasting Blood Sugar Level : It is the blood sugar level of a person when his or her stomach is empty. Blood sugar level testing is done both in empty stomach and after meal. Every person's blood sugar level goes high immediately after eating. So diabetes is mainly determined by fasting blood sugar level which is higher in diabetic patients.