Diabetic neuropathy – the specific damage of a peripheral part of the nervous system caused by dismetabolichesky processes at diabetes. Diabetic neuropathy is shown by sensitivity violation (paresteziya, a sleep of extremities), vegetative dysfunction (tachycardia, hypotension, a dysphagy, diarrhea, angidrozy), urinogenital frustration etc. At diabetic neuropathy inspection of functioning of endocrine, nervous, warm, digestive, urinary systems is made. Treatment includes insulin therapy, use of neyrotropny medicines, antioxidants, purpose of symptomatic therapy, acupuncture, FTL, LFK.
Diabetic neuropathy – one of the most frequent complications of diabetes revealed at 30-50% of patients. Speak about diabetic neuropathy in the presence of signs of damage of peripheral nerves at persons with diabetes at an exception of other reasons of dysfunction of nervous system. Diabetic neuropathy is characterized by violation of nervous conductivity, sensitivity, frustration from somatic and/or the autonomic nervous system. In view of plurality of clinical manifestations experts should face diabetic neuropathy in the field of endocrinology, neurology, gastroenterology, dermatology, a podiatriya, urology, gynecology, cardiology.
Classification of diabetic neuropathy
Depending on topography distinguish peripheral neuropathy with primary involvement in pathological process of spinal nerves and autonomous neuropathy – at violation of an innervation of internals. According to posindromny classification of diabetic neuropathy allocate:
I. Syndrome of generalized symmetric polyneuropathy:
- With primary damage of sensitive nerves (touch neuropathy)
- With primary damage of motive nerves (motor neuropathy)
- With the combined damage of sensitive and motive nerves (sensomotorny neuropathy)
- Hyper glycemic neuropathy.
II. Syndrome of vegetative (autonomous) diabetic neuropathy:
III. Syndrome of focal or multifocal diabetic neuropathy:
- Kranialny neuropathy
- Tunnel neuropathy
- Chronic Inflammatory Demiyeliniziruyushchy Polyneuropathy (CIDP).
A number of authors allocates the central neuropathy and its following forms: diabetic encephalopathy (entsefalomiyelopatiya), sharp vascular brain frustration (PNMK, a stroke), sharp mental disorders caused by a metabolism decompensation.
On the clinical classification considering displays of diabetic neuropathy distinguish several stages of process:
1. Subclinical neuropathy
2. Clinical neuropathy:
- chronic painful form
- sharp painful form
- bezbolevy form in a combination to decrease or total loss of sensitivity
3. Stage of late complications (neyropatichesky deformation of feet, diabetic foot, etc.).
Reasons of diabetic neuropathy
Diabetic neuropathy belongs to metabolic polyneuropathies. The special role in pathogenesis of diabetic neuropathy belongs to neurovascular factors – the mikroangiopatiya breaking blood supply of nerves. The multiple metabolic violations developing on this background finally lead to hypostasis of nervous tissue, disorder of exchange processes in nervous fibers, to violation of carrying out nervous impulses, strengthening of an oxidizing stress, development of autoimmune complexes and, finally, – to an atrophy of nervous fibers.
As factors of the increased risk of development of diabetic neuropathy serve the age, duration of a course of diabetes, an uncontrollable hyperglycemia, arterial hypertension, a giperlipidemiya, obesity, smoking.
Symptoms of diabetic neuropathy
Peripheral polyneuropathy is characterized by development of a complex of motive and sensitive frustration which are most expressed from extremities. Diabetic neuropathy is shown by burning, a sleep, a skin pricking; toes pain and feet, fingers of hands; short-term spasms of muscles.
Tolerance to temperature irritants, hypersensibility to touches, even to very easy can develop. These symptoms, as a rule, amplify at night. Diabetic neuropathy is followed by muscular weakness, easing or loss of reflexes that leads to change of gait and an incoordination of movements. The exhausting pains and paresteziya lead to sleeplessness, appetite loss, weight loss, oppression of a mental condition of patients – a depression.
Ulcer defects of foot, molotkoobrazny deformation of toes, foot arch collapse can be late complications of peripheral diabetic neuropathy. Peripheral polyneuropathy quite often precedes a neyropatichesky form of a syndrome of diabetic foot.
Autonomous diabetic neuropathy can develop and proceed in the form of cardiovascular, gastrointestinalny, urogenital, sudomotorny, respiratory, etc. the forms which are characterized by violation of functions of separate bodies or the whole systems.
The cardiovascular form of diabetic neuropathy can develop in the first 3–5 years of a course of diabetes. It is shown by tachycardia at rest, orthostatic hypotension, changes of the ECG (lengthening of an interval of QT) increased by risk of bezbolevy ischemia of a myocardium and a heart attack.
The Gastrointestinalny form of diabetic neuropathy is characterized by a flavoring gipersalivation, gullet dyskinesia, deep violations motor functions of a stomach (gastroparezy), development of a pathological gastro-ezofagealny reflux (a dysphagy, heartburn, an ezofagit). At patients with diabetes gipoatsidny gastritises, the stomach ulcer of a stomach associated with Helicobacter pylori are frequent; the risk of dyskinesia of a gall bladder and cholelithiasis is increased. Damage of intestines at diabetic neuropathy is followed by violation of a vermicular movement with development of dysbacteriosis, watery diarrhea, a steatorea, locks, incontiences a calla. From a liver quite often comes to light fatty .
At an urogenital form of autonomous diabetic neuropathy the tone of a bladder and mochetochnik is broken that can be followed by a delay of an urination or an incontience of urine. Patients with diabetes are inclined to development of uric infections (cystitis, pyelonephritis). Men can show complaints to erectile dysfunction, violation of a painful innervation of testicles; women – on dryness of a vagina, an anorgazmiya.
Sudomotorny violations at diabetic neuropathy are characterized disteel hypo – and angidrozy (decrease in perspiration of feet and palms) at development of a compensatory central gipergidroz, especially during meal and at night. The respiratory form of diabetic neuropathy proceeds with episodes , a hyperventilation of lungs, decrease in production of surfactant. At diabetic neuropathy the diplopiya, a symptomatic gemeralopiya, thermal control violations, an asymptomatic hypoglycemia, "a diabetic kakheksiya" - the progressing exhaustion quite often develops.
Diagnosis of diabetic neuropathy
The diagnostic algorithm depends on a form of diabetic neuropathy. On primary consultation the anamnesis and complaints to changes from cardiovascular, digestive, respiratory, urinogenital, visual systems are carefully analyzed. At patients with diabetic neuropathy determination of level of glucose, insulin, S-peptide, glikozilirovanny hemoglobin of blood is necessary; a pulsation research on peripheral arteries, measurement HELL; carrying out survey of the lower extremities regarding existence of deformations, fungal defeats, natoptyshy and callosities.
Depending on manifestations other experts – the cardiologist, the gastroenterologist, the neurologist, the ophthalmologist, the urologist-andrologist, the gynecologist, the orthopedist, the chiropodist can participate in diagnosis of diabetic neuropathy, except the endocrinologist and a diabetolog. Primary inspection of cardiovascular system consists in carrying out the ECG, cardiovascular tests (Valsalva's test, orthostatic test, etc.), EhoKG; determination of level of cholesterol and lipoproteid.
Neurologic inspection concerning diabetic neuropathy includes carrying out electrophysiological researches: an electromyography, an elektroneyrografiya, the caused potentials. Assessment of reflexes and different types of touch sensitivity is made: tactile with use of a monofilament; vibration - by means of a tuning fork; temperature - by a touch of a cold or warm subject; painful - a skin pricking method the stupid party of a needle; propriotseptivny – by means of test on stability in Romberg's pose. Resort to a biopsy of a sural nerve and a biopsy of skin at atypical forms of diabetic neuropathy.
Gastroenterologichesky inspection at diabetic neuropathy assumes performing ultrasonography of abdominal organs, EGDS, X-ray analysis of a stomach, a barium passage research on a small intestine, tests on a helikobakter. At complaints from an urinary system the general analysis of urine is investigated, ultrasonography of kidneys, a bladder (including ultrasonography with definition of residual urine), a tsistoskopiya, intravenous urography, an electromyography of muscles of a bladder, etc. is carried out.
Treatment of diabetic neuropathy
Treatment of diabetic neuropathy is carried out consistently and step by step. Effective therapy of diabetic neuropathy is impossible without achievement of compensation of diabetes. Insulin or the tableted antidiabetic medicines are for this purpose appointed, monitoring of level of glucose is carried out. Within an integrated approach in treatment of diabetic neuropathy development of an optimum food allowance and mode of physical activities, decrease in excess body weight, maintenance of normal level of arterial pressure is necessary.
During a basic course reception of neyrotropny vitamins (group B), antioxidants (alpha lipoic acid, vitamin E), minerals is shown (medicines Mg and Zn). At a painful form of diabetic neuropathy purpose of analgetics, anticonvulsive means is expedient.
Physiotherapeutic methods of treatment are useful: electrostimulation of nerves, magnetotherapy, laser therapy, svetoterapiya; acupuncture, LFK. At diabetic neuropathy especially careful care of feet is necessary: carrying convenient (according to indications – orthopedic) footwear; performance of a medical pedicure, foot bathtubs, moistening of feet etc. Treatment of autonomous forms of diabetic neuropathy is carried out taking into account the developed syndrome.
Forecast and prevention of diabetic neuropathy
Early detection of diabetic neuropathy (both peripheral, and autonomous) – pledge of the favorable forecast and improvement of quality of life of patients. Initial stages of diabetic neuropathy can be reversible due to achievement of permanent compensation of diabetes. The complicated diabetic neuropathy is the leading risk factor of bezbolevy myocardial infarctions, violations of a warm rhythm, not traumatic amputations of the lower extremities.
For the purpose of prevention of diabetic neuropathy constant control of level of sugar of blood, timely correction of treatment, regular observation at a diabetolog, etc. experts is necessary.