Like hypoglycemia, dehydrating illness canbelife-threatening to a di abetic.
Encourage the people you live with to read this chapter care fully.
The supplies mentioned should be kept in locations known to all.
Phone yourphysician at the first sign of fever, diarrhea, or vomit ing.
The chances are that he/she would much rather be contacted early, when dehydration and loss of blood sugar control can be pre vented.
Emergency situations make treatment more difficult, so you canmake yourlife andyour physician's a bit easier byphoning before major problems occur.
Your physician will probably ask you whether yoururine shows ke tones, so use the Ketostix whenever you urinate beforeyou call.Also, let your doctor know if you have taken any aspirin in the prior 24 hours, as this can cause a false positive Ketostix reading.If you are not eating, your urine will certainly show"moderate" ketones.
Your physi-
How toCope with Dehydration, Dehydrating Illness, and Infection 355
cian should therefore only be concerned if it shows "high" ketones combined with high blood sugars (160 mg/dl or above). Always report yourrecent bloodsugars when you phone yourphysician.
NONDEHYDRATING INFECTIONS
Most infections cancause elevation of blood sugars, from an infected toe to infected tonsils to infected heart valves.
Most infections cause symptoms that are recognizable, such as burning upon urination if you have a urinary tract infection, coughing if you have bronchitis, and so on.
So you'll get pretty prompt warning from your body that you should immediately contact your physician.
Ifyou have type 2 di abetes or early type 1, you certainly don't want your blood sugars to get sohigh thatyour remaining beta cells are destroyed.
My friend Jay put offvisiting a urologist until his blood sugars got so high that his type 2 diabetes became type 1diabetes andherequired 5 daily insulin injections.
Occult, or hidden, infections will not become readily ap parent unless you notice that your blood sugars have become unrea sonably high andyou have the good judgment tocontact your doctor.
By far the most common type of occult infection is that family of infections that affect dental structures.
This includes infections that affect root canals, gums, and jawbones.
A history of elevated blood sugars over a period of years predisposes diabetics to such infections; these infections, inturn, predispose diabetics tohigh blood sugars and severe insulin resistance.
If one of my patients calls ouroffice and complains of recent onset high blood sugars but no apparent accompanying infection (no coughing, for instance), we ask ifshe orhe is reusing insulin syringes and contaminating insulin, making injections relatively ineffective (see page 257).
If the answeris no, then we recommend a visit to the dentist immediately to search for an oral infection.
Among the things thatyour dentist should do are to examine your gumsverycarefully and to tap every tooth to seeif one or more is ten der.
He or she should also touch each tooth with a chip of ice.
Pain upon exposure to cold is the most common overt symptom of infec tion in the tooth or jawbone, in my experience.
We have had patients with dentists who refused to dothis and we've had to instruct thepa tients to find better dentists.
This is one ofthose many cases of being a good, educated health care consumer in order to get proper treat-
356 Treatment
ment for your diabetes.
In each case, when a new dentist performed thesetests, a problem was found.
If yourdentist does find a problem, he or shewill probably refer you to anendodontist or periodontist to treat the infection.
Even after such dental infections have been successfully treated, however, bloodsugar elevations frequently continue for manymonths.
If this occurs, an appropriate antibiotic shouldbe prescribed and con tinued until blood sugars remain at their preinfection level.
Many people require continuation of antibiotics for as long as a year after treatment to prevent further blood sugar increases.
When using oral antibiotics, always take a probiotic every day,* at least 2 hours before or after the antibiotic, to replace gastrointestinal bacteria killedby the antibiotic.
To help prevent dental infections, it is wise to arrange with your dentist for tartar to be removed from your teeth ultrasonically every three months.
You should also brush your teeth at leasttwice dailyand aftermeals floss frombetween yourteeth any foodthat remains there.
If your teeth are too tightly spaced for flossing, try Stimudent, which isa specially designed toothpick withatriangular cross-section.
Push it between yourteeth with the base of the triangle against your gum.
An even easier productto useis Doctor's BrushPicks, available at most pharmacies.
*My current favorite probiotic issaccharomyces boulardii (brand name Floras- tor). It is availableat most pharmacies.
22 Delayed Stomach«Emptying: Gastroparesis
A number of times throughout this book, you've come across the terms "delayed stomach-emptying" and "gastroparesis." As I explained in Chapter 2, elevated blood sugars for pro longed periods can impair the ability ofnerves to function properly.
It's very common that the nerves that stimulate the muscular activity, enzyme secretion, and acid production essential to digestion function poorly in long-standing diabetes.
These changes affect the stomach, the gut, or both.
Dr.
Richard McCullum, a noted authority on diges tion, has said that ifa diabetic has any other form ofneuropathy (dry feet, reduced feeling in the toes, diminished reflexes, et cetera), he or she will also experience delayed or erratic digestion.
Slowed digestion can befraught with unpleasant symptoms (rarely), or it may only be detectable when we review blood sugar profiles (commonly) or perform certain diagnostic tests.
The picture isdiffer ent for each of us.
For more than twenty-five years, I suffered from many unpleasant symptoms myself.
I eventually saw them taper off and vanish after thirteen years of essentially normal blood sugars.
Some ofthephysical complaints possible (usually after meals) include burning along the midline ofthe chest ("heartburn"), belching, feel ing full after a small meal (early satiety), bloating, nausea, vomiting, constipation, constipation alternating with diarrhea, cramps a few inches above the bellybutton, and an acidtaste in the mouth.
GASTROPARESIS: CAUSES AND EFFECTS
Most of these symptoms, as well as effects upon blood sugar, relate to delayed stomach-emptying. This condition iscalled gastroparesis dia-
358 Treatment
beticorum, which translates from the Latin as "weak stomach of dia betics." It is believedthat the major cause of this condition is neuropa thy (nerve impairment) of thevagus nerve.
This nerve mediates many of the autonomicor regulatory functions of the body, including heart rate and digestion.
In men, neuropathy of the vagus nerve can also lead to difficulty in achieving penile erections.
To understand the ef fects of gastroparesis, refer to Figure 22-1.
On theleft is a representation ofa normal stomach after a meal.
The contents are emptying into the intestines, through the pylorus.
The pyloric valve is wide open (relaxed).
The lower esophageal sphincter (LES) is tightly closed, to prevent regurgitation of stomach contents.
Notshown isthe grinding andchurning activity of the muscular walls of the normal stomach.
On the right is pictured a stomach with gastroparesis.
The normal rhythmic motions ofthe stomach walls are absent.
The pyloric valve is tightly closed, preventing the unloading of stomach contents.
A tiny opening aboutthesize ofa pencil pointmay permit a small amount of fluid to dribble out.When the pyloric valve is in tightspasm, some of us can sometimes feel a sharp cramp above the belly button.
Since the
Esophagus-
LES
Stomach
Pyloric Valve
Normal Stomach Paretic Stomach
Terry Eppridge Fig. 22-1. Normal andparetic stomachs.
Delayed Stomach-Emptying: Gastroparesis 359
lower esophageal sphincter (LES in Figure 22-1) is relaxed or open, acidic stomach contents can back up intothe esophagus (thetubethat connects the throat to the stomach).
This can cause aburning sensa tion along the midline of the chest, especially while the person islying down.
I have seen patients whose teeth were actually eroded over time by regurgitated stomach acid.
Because the stomach does not empty readily, one may feel full even after a small meal.
In extreme cases, severalmeals accumulate and cause severe bloating.
More commonly, however, youmayhave gastroparesis and not be aware of it.
In mild cases, emptying maybe slowed some what, but not enough to make you feel any different Nevertheless, this can cause problems withblood sugar control.
Consuming certain sub stances, such as tricyclic antidepressants, caffeine, fat, and alcohol, can further slow stomach-emptying and other digestive processes.
Some years ago, I received a letter from my friend Bob Anderson.
His diabetic wife, Trish, who was not my patient andhas since passed away, hadbeen experiencing frequent loss of consciousness from severe hypoglycemia, caused by delayed digestion.
His description of an en doscopic exam, when he was allowed to lookthrough a flexible tube into Trish's stomach and gut, paints a graphic picture.
Allthisbrings me to today's endoscopy exam.
I watched through the scope and for the first time, I nowunderstand whatyou have been saying about diabetic gastroparesis.
Not until I viewed the inside of the duodenum did I understand the catastrophic effect of 33 years of diabetes upon the internal organs.
There was al most no muscle action apparent to move food out of the stom ach.
It appeared as a very relaxed smooth-sided tube instead of having muscular ridges ringing the passage.
I suppose a picture is worth a thousand words.
Diabetic neuropathy is more than a manifestation of atilting gait, blindness, andother easily observ able presentations; it wrecks the whole system.
This you well know.
I am learning.
HOW DOES GASTROPARESIS AFFECT BLOOD SUGAR CONTROL?
Consider the individual who has very little phase I insulin release and must take fast-acting insulin orone of theolder-type (sulfonylurea) or
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