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Why Does Dka Cause Abdominal Pain

Diabetic Ketoacidosis And Hyperosmolar Hyperglycemic State In Adults: Clinical Features, Evaluation, And Diagnosis

Diabetic Ketoacidosis And Hyperosmolar Hyperglycemic State In Adults: Clinical Features, Evaluation, And Diagnosis

INTRODUCTION Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS, also known as hyperosmotic hyperglycemic nonketotic state [HHNK]) are two of the most serious acute complications of diabetes. DKA is characterized by ketoacidosis and hyperglycemia, while HHS usually has more severe hyperglycemia but no ketoacidosis (table 1). Each represents an extreme in the spectrum of hyperglycemia. The precipitating factors, clinical features, evaluation, and diagnosis of DKA and HHS in adults will be reviewed here. The epidemiology, pathogenesis, and treatment of these disorders are discussed separately. DKA in children is also reviewed separately. (See "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Epidemiology and pathogenesis".) Continue reading >>

Received: December 10, 2014 Accepted: December 21, 2014 Online Published: December 29, 2014 Doi: 10.5430/crim.v2n1p96 Url:

Received: December 10, 2014 Accepted: December 21, 2014 Online Published: December 29, 2014 Doi: 10.5430/crim.v2n1p96 Url:

Case Reports in Internal Medicine, 2015, Vol. 2, No. 1 ISSN 2332-7243 E-ISSN 2332-7251 96 CASE REPORT Unusual case of diabetic ketoacidosis Johad F. Khoury1, Daniel A. King2, Eyal Braun3, Mohammad E. Naffaa4 1. Department of Internal Medicine B, Rambam Health Care Campus, Haifa, Israel. 2. Intensive Care Unit, Medical Division, Rambam Health Care Campus, Haifa, Israel. 3. Department of Internal Medicine H and the Infectious Diseases Unit, Rambam Health Care Campus and the Rappaport's Faculty of Medicine, the Technion, Haifa, Israel. 4. Department of Internal Medicine H and the B. Shine Rheumatology Unit, Rambam Health Care Campus and the Rappaport's Faculty of Medicine, the Technion, Haifa, Israel. Correspondence: Mohammad E. Naffaa. Address: Haa'leya Hashneya 8, Bat-Galim, 31096, Haifa, Israel. Email: [email protected] Abstract Type-2 Diabetes mellitus may present in several ways, one of which, is Diabetic Ketoacidosis. Diabetes itself may be caused by acute pancreatitis. We discuss a case of 46 years old male, with no history of diabetes mellitus, who was admitted for abdominal pain and vomiting, and finally diagnosed with diabetic ketoacidosis. Serum amylase and lipase could not be measured at admission owing to the heavily lipemic serum. Subsequent measures demonstrated very high levels of lipase. Serum triglycerides were significantly elevated; 3200 mg/dl. Initial computed tomography scan of the abdomen did not reveal findings typical for acute pancreatitis. Hypertriglyceridemia-induced pancreatitis leading to overt diabetic ketoacidosis in a previously non-diabetic patient was our leading diagnosis. Lipo-pharesis was instituted shortly after the initiation of intra-venous insulin and fluid resus- citation. Subcutaneous heparin and fibrates were added l Continue reading >>

Diabetic Emergencies, Part 5: Dka Case Studies

Diabetic Emergencies, Part 5: Dka Case Studies

Case Study 1 A 32-year-old male with type 1 diabetes since the age of 14 years was taken to the emergency room because of drowsiness, fever, cough, diffuse abdominal pain, and vomiting. Fever and cough started 2 days ago and the patient could not eat or drink water. He has been treated with an intensive insulin regimen (insulin glargine 24 IU at bedtime and a rapid-acting insulin analog before each meal). On examination he was tachypneic, his temperature was 39° C (102.2° F), pulse rate 104 beats per minute, respiratory rate 24 breaths per minute, supine blood pressure 100/70 mmHg; he also had dry mucous membranes, poor skin turgor, and rales in the right lower chest. He was slightly confused. Rapid hematology and biochemical tests showed hematocrit 48%, hemoglobin 14.3 g/dl (143 g/L), white blood cell count 18,000/ μ l, glucose 450 mg/dl (25.0 mmol/L), urea 60 mg/dl (10.2 mmol/L), creatinine 1.4 mg/dl (123.7 μ mol/L), Na+ 152 mEq/L, K+ 5.3 mEq/L, PO4 3−2.3 mEq/L (0.74 mmol/L), and Cl− 110 mmol/L. Arterial pH was 6.9, PO 2 95 mmHg, PCO 2 28 mmHg, HCO 3−9 mEq/L, and O 2 sat 98%. The result of the strip for ketone bodies in urine was strongly positive and the concentration of β-OHB in serum was 3.5 mmol/L. Urinalysis showed glucose 800 mg/dl and specific gravity 1030. What is your diagnosis? The patient has hyperglycemia, ketosis, and metabolic acidosis. Therefore, he has DKA. In addition, because of the pre-existing fever, cough, localized rales on auscultation and high white blood cell count, a respiratory tract infection should be considered. The patient is also dehydrated and has impaired renal function. Do you need more tests to confirm the diagnosis? Determination of the effective serum osmolality and anion gap should be performed in all patients presenti Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Abbas E. Kitabchi, PhD., MD., FACP, FACE Professor of Medicine & Molecular Sciences and Maston K. Callison Professor in the Division of Endocrinology, Diabetes & Metabolism UT Health Science Center, 920 Madison Ave., 300A, Memphis, TN 38163 Aidar R. Gosmanov, M.D., Ph.D., D.M.Sc. Assistant Professor of Medicine, Division of Endocrinology, Diabetes & Metabolism, The University of Tennessee Health Science Center, 920 Madison Avenue, Suite 300A, Memphis, TN 38163 Clinical Recognition Omission of insulin and infection are the two most common precipitants of DKA. Non-compliance may account for up to 44% of DKA presentations; while infection is less frequently observed in DKA patients. Acute medical illnesses involving the cardiovascular system (myocardial infarction, stroke, acute thrombosis) and gastrointestinal tract (bleeding, pancreatitis), diseases of endocrine axis (acromegaly, Cushing`s syndrome, hyperthyroidism) and impaired thermo-regulation or recent surgical procedures can contribute to the development of DKA by causing dehydration, increase in insulin counter-regulatory hormones, and worsening of peripheral insulin resistance. Medications such as diuretics, beta-blockers, corticosteroids, second-generation anti-psychotics, and/or anti-convulsants may affect carbohydrate metabolism and volume status and, therefore, could precipitateDKA. Other factors: psychological problems, eating disorders, insulin pump malfunction, and drug abuse. It is now recognized that new onset T2DM can manifest with DKA. These patients are obese, mostly African Americans or Hispanics and have undiagnosed hyperglycemia, impaired insulin secretion, and insulin action. A recent report suggests that cocaine abuse is an independent risk factor associated with DKA recurrence. Pathophysiology In Continue reading >>

An Exceptional Case Of Diabetic Ketoacidosis

An Exceptional Case Of Diabetic Ketoacidosis

Copyright © 2017 Celine Van de Vyver et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract We present a case of diabetic ketoacidosis, known as one of the most serious metabolic complications of diabetes. We were confronted with rapid neurological deterioration and unseen glycaemic values, which reached almost 110 mmol/L, subsequently resulting in hyperkalaemia and life-threatening dysrhythmias. This is the first reported live case with such high values of blood glucose and a favourable outcome. 1. Introduction Diabetic ketoacidosis (DKA) is known as one of the most serious complications of diabetes, besides hyperosmolar hyperglycaemic syndrome (HHS), and it is associated with significant morbidity and mortality. The symptoms are often nonspecific and there are many diseases that mimic the presentation. The clinical course usually evolves within a short time frame (<24 h). DKA exists of a triad of uncontrolled hyperglycaemia, metabolic acidosis, and increased total body ketone concentration [1]. These three criteria are needed for diagnosis. The most common precipitating factors of DKA are infections and discontinuation of or inadequate insulin therapy. Mainstays of treatment are correction of hypovolemia and hyperglycaemia, rapid administration of insulin, and electrolyte management. Glycaemic values in DKA normally do not exceed 33 mmol/L. In contrast, blood glucose in HHS is often higher [2, 3]. We present a case of severe diabetic ketoacidosis with glycaemic values of almost 110 mmol/L, leading to neurologic sequelae and requiring more aggressive treatment. A similar case report detailing th Continue reading >>

The Etiology Of Abdominal Pain In Diabetic Acidosis*

The Etiology Of Abdominal Pain In Diabetic Acidosis*

The usual signs, symptoms, and laboratory findings in prediabetic coma are well known. The clinical picture of dehydration associated with malnutrition, polyuria, and odor of acetone on the breath, decreased intraocular tension, and Kussmaul breathing, when found in conjunction with sugar and acetone bodies in the urine make a clinical picture that could hardly be confused with any other condition. Other laboratory findings are a high blood sugar, a low CO2 combining power of the blood plasma, and leukocytosis. The white cell count sometimes rises above 65,0001 per cubic millimeter of blood. This picture is usually clear cut and offers Continue reading >>

Ketoacidosis

Ketoacidosis

Glucose (a type of sugar) is the body's main energy source. But when the body can't use glucose for fuel - like when a person has untreated diabetes - the body breaks down fat for energy instead. When fat is broken down, the body produces chemicals called ketones, which appear in the blood and urine. High levels of ketones cause the blood to become more acidic. This is known as ketoacidosis (it's called diabetic ketoacidosis, or DKA, when uncontrolled diabetes is the cause). Ketoacidosis is a severe life-threatening condition requiring immediate treatment. Symptoms of ketoacidosis include nausea, vomiting, abdominal pain, rapid breathing, and, in severe cases, unconsciousness. Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

A Preventable Crisis People who have had diabetic ketoacidosis, or DKA, will tell you it’s worse than any flu they’ve ever had, describing an overwhelming feeling of lethargy, unquenchable thirst, and unrelenting vomiting. “It’s sort of like having molasses for blood,” says George. “Everything moves so slow, the mouth can feel so dry, and there is a cloud over your head. Just before diagnosis, when I was in high school, I would get out of a class and go to the bathroom to pee for about 10–12 minutes. Then I would head to the water fountain and begin drinking water for minutes at a time, usually until well after the next class had begun.” George, generally an upbeat person, said that while he has experienced varying degrees of DKA in his 40 years or so of having diabetes, “…at its worst, there is one reprieve from its ill feeling: Unfortunately, that is a coma.” But DKA can be more than a feeling of extreme discomfort, and it can result in more than a coma. “It has the potential to kill,” says Richard Hellman, MD, past president of the American Association of Clinical Endocrinologists. “DKA is a medical emergency. It’s the biggest medical emergency related to diabetes. It’s also the most likely time for a child with diabetes to die.” DKA occurs when there is not enough insulin in the body, resulting in high blood glucose; the person is dehydrated; and too many ketones are present in the bloodstream, making it acidic. The initial insulin deficit is most often caused by the onset of diabetes, by an illness or infection, or by not taking insulin when it is needed. Ketones are your brain’s “second-best fuel,” Hellman says, with glucose being number one. If you don’t have enough glucose in your cells to supply energy to your brain, yo Continue reading >>

What’s Bugging Your Gut? Diabetes, Ibs Or Both?

What’s Bugging Your Gut? Diabetes, Ibs Or Both?

If you have “gut issues” – meaning diarrhea, constipation, cramping, abdominal pain or nausea – and you have diabetes, you are not alone. In fact, this relationship is more common than you – or your doctor – may realize. Up to 75% of people with diabetes have at least one gastrointestinal symptom. These GI problems can include diarrhea, constipation, abdominal pain, and vomiting. The most common GI problem that results in diarrhea is Irritable Bowel Syndrome (IBS) and the links between gut problems, namely IBS and blood sugars are tightly woven and interconnected. Even the severity of symptoms is closely linked to the glycemic control of the individual. Meaning the worse the glycemic control, the worse the GI symptoms. High blood sugars make it hard for the stomach and small intestine to work normally. At the same time, IBS itself can make it harder for your body to control post-prandial (or “after meal”) blood sugars. A Missed Diagnosis and Continued Suffering Sadly, people with diabetes suffer from the effect of undiagnosed IBS or other digestive disruption every day. Some people with diabetes are told their abdominal pain and gastrointestinal discomfort is just a complication of their poorly controlled blood sugars—leaving Irritable Bowel Syndrome (or other digestive disorders) undiagnosed and, therefore, untreated. To complicate matters further, symptoms of both diabetes and IBS are greatly impacted by diet, stress, and general health. In diabetes, GI problems are often related to what’s referred to as autonomic gastrointestinal neuropathy resulting in abnormal motility. “Motility” refers to your body’s ability to move through the digestive system – including your stomach, small and large intestine at the right speed: not too fast, not to Continue reading >>

Hyperglycaemic Crises And Lactic Acidosis In Diabetes Mellitus

Hyperglycaemic Crises And Lactic Acidosis In Diabetes Mellitus

Hyperglycaemic crises are discussed together followed by a separate section on lactic acidosis. DIABETIC KETOACIDOSIS (DKA) AND HYPERGLYCAEMIC HYPEROSMOLAR STATE (HHS) Definitions DKA has no universally agreed definition. Alberti proposed the working definition of “severe uncontrolled diabetes requiring emergency treatment with insulin and intravenous fluids and with a blood ketone body concentration of >5 mmol/l”.1 Given the limited availability of blood ketone body assays, a more pragmatic definition comprising a metabolic acidosis (pH <7.3), plasma bicarbonate <15 mmol/l, plasma glucose >13.9 mmol/l, and urine ketostix reaction ++ or plasma ketostix ⩾ + may be more workable in clinical practice.2 Classifying the severity of diabetic ketoacidosis is desirable, since it may assist in determining the management and monitoring of the patient. Such a classification is based on the severity of acidosis (table 1). A caveat to this approach is that the presence of an intercurrent illness, that may not necessarily affect the level of acidosis, may markedly affect outcome: a recent study showed that the two most important factors predicting mortality in DKA were severe intercurrent illness and pH <7.0.3 HHS replaces the older terms, “hyperglycaemic hyperosmolar non-ketotic coma” and “hyperglycaemic hyperosmolar non-ketotic state”, because alterations of sensoria may be present without coma, and mild to moderate ketosis is commonly present in this state.4,5 Definitions vary according to the degree of hyperglycaemia and elevation of osmolality required. Table 1 summarises the definition of Kitabchi et al.5 Epidemiology The annual incidence of DKA among subjects with type 1 diabetes is between 1% and 5% in European and American series6–10 and this incidence appear Continue reading >>

Symptoms And Detection Of Ketoacidosis

Symptoms And Detection Of Ketoacidosis

Symptoms These symptoms are due to the ketone poisoning and should never be ignored. As soon as a person begins to vomit or has difficulty breathing, immediate treatment in an emergency room is required to prevent coma and possible death. Early Signs, Symptoms: Late Signs, Symptoms: very tired and sleepy weakness great thirst frequent urination dry skin and tongue leg cramps fruity odor to the breath* upset stomach* nausea* vomiting* shortness of breath sunken eyeballs very high blood sugars rapid pulse rapid breathing low blood pressure unresponsiveness, coma * these are more specific for ketoacidosis than hyperosmolar syndrome Everyone with diabetes needs to know how to recognize and treat ketoacidosis. Ketones travel from the blood into the urine and can be detected in the urine with ketone test strips available at any pharmacy. Ketone strips should always be kept on hand, but stored in a dry area and replaced as soon as they become outdated. Measurement of Ketones in the urine is very important for diabetics with infections or on insulin pump therapy due to the fact it gives more information than glucose tests alone. Check the urine for ketones whenever a blood sugar reading is 300 mg/dl or higher, if a fruity odor is detected in the breath, if abdominal pain is present, if nausea or vomiting is occurring, or if you are breathing rapidly and short of breath. If a moderate or large amount of ketones are detected on the test strip, ketoacidosis is present and immediate treatment is required. Symptoms for hyperglycemic hyperosmolar syndrome are linked to dehydration rather than acidosis, so a fruity odor to the breath and stomach upset are less likely. How To Detect Ketones During any illness, especially when it is severe and any time the stomach becomes upset, ketone Continue reading >>

Significance Of Hyperamylasaemia And Abdominal Pain In Diabetic Ketoacidosis

Significance Of Hyperamylasaemia And Abdominal Pain In Diabetic Ketoacidosis

Since scans are not currently available to screen readers, please contact JSTOR User Support for access. We'll provide a PDF copy for your screen reader. Abstract An analysis of 35 consecutive episodes of diabetic ketoacidosis confirmed the frequent high levels of serum amylase in this condition. Serum amylase was raised during 21 episodes (60%), and in six instances (17%) the peak level exceeded 1,000 Somogyi units per 100 ml. Hyperamylasaemia was more often found when the initial blood sugar exceeded 500 mg/100 ml, or when the onset of the episode had been relatively acute (less than 48 hours). There was no conclusive evidence in any patient to support a diagnosis of acute pancreatitis and other explanations for the hyperamylasaemia are discussed. Even grossly raised amylase levels were not associated with increased mortality or morbidity. Continue reading >>

Ketones — The 6 Must-knows

Ketones — The 6 Must-knows

WRITTEN BY: Kyla Schmieg, BSN, RN Editor’s Note: Kyla Schmieg (BSN, RN) is a practicing pediatric endocrinology nurse in Cincinnati, OH, USA, and Type 1 Diabetic, working on the same unit she was diagnosed at 26 years ago. 1 – What are ketones? Ketones are chemicals that build up when your body starts to burn fat for energy. The most common cause of ketones in diabetics is insulin deficiency. Without enough insulin, glucose builds up in the blood stream and can’t enter cells. The cells then burn fat instead of glucose. This results in ketones forming in the blood and eventually spilling into urine. 2 – Why can ketones be dangerous? Having ketones can indicate that your body needs more insulin. (Always monitor your blood sugar levels to know how much insulin you need.) If you have a build up of ketones, this can lead to Diabetic Ketoacidosis (DKA). Signs of DKA include moderate or large ketones, nausea, vomiting, abdominal pain, fruity or acetone (think nail polish remover) breath, rapid breathing, flushed skin, and lack of energy. If left untreated, it can lead to a serious and life-threatening diabetic coma or death. High levels of ketones are toxic to the body and if you’re experiencing these, you should seek out medical attention. 3 – When should you check for ketones? You should be checked anytime your blood sugar is above 240 mg/dl (13.3 mmol/l) or any time you are sick. This includes any minor illness such as a cold. 4 – Can you get ketones with a high blood sugar? Ketones typically accompany high blood sugar. They indicate that your body needs more insulin. Most often if your body needs more insulin, it means you probably have a high blood sugar. Also, when an illness is present, your body releases hormones in response to the stress. These hormones Continue reading >>

What Are The Causes Of Pain On The Right Side Under The Bottom Rib?

What Are The Causes Of Pain On The Right Side Under The Bottom Rib?

According to the Merck Manuals Online Medical Library, pain that manifests in the abdomen, including the right upper abdominal quadrant, can be caused by the viscera or abdominal organs, structures outside the abdomen or the parietal peritoneum -- the membrane that lines the abdominal wall. When it arises suddenly, right upper abdominal pain may indicate a serious underlying health concern. Video of the Day Acute cholecystitis can cause pain in the right upper abdomen, below the bottom rib. According to MedlinePlus, acute cholecystitis is a sudden inflammation of the gallbladder that is characterized by extreme abdominal pain. Most cases of acute cholecystitis -- approximately 90 percent -- are caused by gallstones that trap bile, an important digestive aid, inside the gallbladder. Other possible causes of acute cholecystitis include gallbladder tumors and serious illness. Common signs and symptoms associated with acute cholecystitis include sharp, cramping or dull pain in the right upper abdominal quadrant, the sensation of abdominal fullness, clay-colored stools, fever, nausea, vomiting and jaundice -- yellowing of the skin and the whites of the eyes. MedlinePlus states that gallstones are more common in women than men. Typhoid fever can cause pain on the right side of the abdomen, under the bottom rib. MayoClinic.com states that typhoid fever is caused by Salmonella typhi bacteria. Although typhoid fever is uncommon in industrialized nations, it is still a significant health threat in developing countries. Typhoid fever can spread in one of two possible ways: via contaminated food and water or through close contact with an infected individual. Typhoid fever-related symptoms tend to develop gradually. Common signs and symptoms associated with typhoid fever include abd Continue reading >>

Alcoholic Ketoacidosis

Alcoholic Ketoacidosis

What is alcoholic ketoacidosis? Cells need glucose (sugar) and insulin to function properly. Glucose comes from the food you eat, and insulin is produced by the pancreas. When you drink alcohol, your pancreas may stop producing insulin for a short time. Without insulin, your cells won’t be able to use the glucose you consume for energy. To get the energy you need, your body will start to burn fat. When your body burns fat for energy, byproducts known as ketone bodies are produced. If your body is not producing insulin, ketone bodies will begin to build up in your bloodstream. This buildup of ketones can produce a life-threatening condition known as ketoacidosis. Ketoacidosis, or metabolic acidosis, occurs when you ingest something that is metabolized or turned into an acid. This condition has a number of causes, including: shock kidney disease abnormal metabolism In addition to general ketoacidosis, there are several specific types. These types include: alcoholic ketoacidosis, which is caused by excessive consumption of alcohol diabetic ketoacidosis (DKA), which mostly develops in people with type 1 diabetes starvation ketoacidosis, which occurs most often in women who are pregnant, in their third trimester, and experiencing excessive vomiting Each of these situations increases the amount of acid in the system. They can also reduce the amount of insulin your body produces, leading to the breakdown of fat cells and the production of ketones. Alcoholic ketoacidosis can develop when you drink excessive amounts of alcohol for a long period of time. Excessive alcohol consumption often causes malnourishment (not enough nutrients for the body to function well). People who drink large quantities of alcohol may not eat regularly. They may also vomit as a result of drinking too Continue reading >>

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