Endocrinology

Diabetes mellitus and pancreatic diseases: diagnostic errors

Marina Virko
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Wolfram Karges

Diabetes mellitus is one of the most common health problems of our civilization. The modern science that deals with it, called diabetology distinguishes several forms of this disease, varying both in the cause and course, although all of them have the same background, i.e. abnormal glucose metabolism.

A correct and timely identification of causes that lead to the disorder often plays a decisive role in choosing the right treatment and monitoring scheme. This means that it is possible to maintain the quality of life as long as possible, to avoid or bring to the minimum complication risks. However, it is at the stage of determining the disease type, that is, identifying the causes of its development, that mistakes often occur.

What is diabetes mellitus and what are the differences between its types?

When immune processes go wrong, leading to damage of insulin-producing cells, type 1 disease develops. This is a rather rare form. Most people affected by diabetes (about 90%) have the 2nd type. It is related to the fact that the body’s cell sensitivity to insulin is reduced. It is often closely related to other metabolic problems and is part of the so-called metabolic syndrome. Also, depending on the known development mechanism, other specific types of this disorder are distinguished, such as certain genetic defects, pregnancy-related hyperglycemia, etc.

A separate form is pancreatogenic (or pancreatic) diabetes (previously designated as diabetes mellitus type 3c), which occurs due to particular pancreas disorders.

When impaired glucose metabolism is suspected, it is very important to understand which type of diabetes mellitus it is. And it is its pancreatic variant that is often overlooked, leading to an incorrect diagnosis. And this in turn leads to incorrect treatment and monitoring plans.

Why can pancreatic problems lead to impaired glucose metabolism?

The pancreas is one of the largest endocrine organs in the human body, performing vital functions, including producing insulin and glucagon, the hormones which are necessary for the absorption of sugar by body cells. In the case of disease or injury, this function can be impaired. Then glucose cannot be assimilated fully by the cells, so its redundant amounts accumulate in the blood, and a disease known as pancreatic diabetes mellitus occurs. When this diagnosis is made, treatment and monitoring tactics have a number of specific features.

What are the features of pancreas disease-associated diabetes?

The pancreatic variant accounts for up to 10% of all cases of impaired glucose metabolism in the body. However, this type is not always diagnosed correctly in daily clinical practice (less than 3% of cases). As a rule, a wrong diagnosis of type 2 diabetes is made. The pancreatic variant has no single clinical pattern and is characterized by a variety of manifestations. Accordingly, its treatment methods range from diet and lifestyle correction, the use of antidiabetic medications in the form of pills, and up to all forms of insulin administration. Therefore, it is important to determine the causes of the specific symptoms when a glucose metabolism disorder is suspected, and to exclude an endocrine organ disease as their cause. Therefore, when a glucose metabolism disorder is suspected, it is important to establish why the characteristic symptoms occur and to rule out endocrine organ disease as their basis.

Diabetes associated with pancreatic dysfunction has a significantly less favorable course than classical type 2 diabetes. It has been proven that its feature in comparison with type 2 is a significantly higher risk of complications affecting the vascular and nervous systems, kidneys, and eyes. Patients with this kind of diabetes have a 1.74 times higher risk of death than those with other types of the disease.

That is why it is so important to diagnose this condition correctly and, subsequently, to administer the appropriate treatment scheme.

Which pancreatic disorders can lead to the development of the disease?

Acute pancreatitis is associated in 50-70% of cases with transient hyperglycemia and in only 15% of cases lead to abnormal glucose uptake. In 40-50% of patients, chronic pancreatitis results in decreased glucose sensitivity due to decreased beta-cell activity in exocrine pancreatic tissue due to discontinued growth stimulation necessary for insulin-producing cells.

Therefore, the most frequent (over 78%) cause leading to pancreatic diabetes is a chronic inflammatory process (chronic pancreatitis), especially its calcifying variant, which results in diabetes in 90% of cases.

Prolonged inflammation of the pancreas is mostly (70%) a consequence of alcohol abuse, aggravating circumstances are smoking and hereditary factors. It can also be caused by cholecystitis with the formation of gallstones. The chronic process destroys the pancreatic tissue, which is replaced by fibrous scars that do not sustain the function of the organ. As a consequence, insulin release decreases, leading to diabetes.

Diagnosis of this type is based, as with its other forms, on laboratory tests that show glucose metabolism. Knowing about the history or current pancreatitis plays an important role. If such data are absent, and the doctor has clinical reasons to suspect chronic pancreatitis, in-depth diagnostics by special methods is performed.

Patients with chronic pancreatitis are encouraged to undergo annual screenings for endocrine and exocrine insufficiency.

If there is a strong reason to suspect a pancreas-related endocrine disorder, the therapy plan should be of particular character. In the initial stages of the disease, the treatment of choice is a diet and correction of lifestyle, as well as metformin administration, especially if the patient is overweight. The use of sulfonylureas can be considered, but should be avoided. The prescription of drugs based on the effect of the so-called incretins (GFP-1, GIP) in patients with pancreatic diabetes is absolutely contraindicated because of the potential danger of developing acute pancreatitis or even carcinoma.

In some cases, insulin therapy cannot be avoided. More than 45% of patients with chronic pancreatitis become insulin-dependent 5 years after the diagnosis.

The use of the drug pancreatin has no effect on the setting of sugar levels in pancreatic diabetes.

Pancreas injuries, or surgeries involving partial resection can also lead to the development of diabetes mellitus. Naturally, its total removal leads to it in 100% of cases (the most severe forms occur, with extreme metabolic instability). These cases require especially intensive insulin therapy, up to the use of an insulin pump with a system of continuous subcutaneous glucose measurement, allowing the automatic regulation of insulin supply in the case of a threatening drop in its level.

Autotransplantation of insulin-producing tissue is not yet a common practice for a variety of reasons.

In the case of pancreatic cancer, pancreatogenic glucose uptake disorder is present in about 65% of cases by the time the malignancy is diagnosed. But, as a rule, it is identified as a type 2 diabetes and treated accordingly. There are no principal differences in the regimen. However, practice shows that in the case of a malignant lesion, an earlier and more intensive administration of insulin is required.

Accordingly, preventive medicine aims at early detection of pancreatic malignancies, which are characterized by the fact that the symptoms usually manifest themselves at advanced stages, and only in 15% of cases the primary manifestation of endocrine disorder may be one of the symptoms. Effective methods of early detection include lab tests and radiology exams (CT, MRI) and, in particular, endosonography.

If a physician is faced with the need for early and high-dose insulin administration in a patient with a primary diagnosis of type 2 disease, one should consider the possible presence of carcinoma. There is an active effort underway to develop a strategy for early diagnosis of pancreatic cancer at the time of initial hyperglycemia manifestations.

Pancreatic diabetes is also found in other diseases involving the pancreas, such as hemochromatosis and cystic fibrosis/mucoviscidosis. Treatment in such cases has its own peculiarities, which are necessarily taken into account by specialists.

With known pancreatic diseases, regular monitoring with a focus on diagnosing the early stages of glucose metabolism disorder is very important. Timely dietary habits and whole lifestyle correction, as well as drug therapy, will help prolong life and avoid severe complications.

Accordingly, patients diagnosed with type 2 diabetes should also be monitored for possible pancreatic disease as a factor “responsible” for diabetes.

Can additional medical advice be of use in the case of diabetes?

Any doubts about the efficacy of administered therapy or its compliance with current standards are sufficient grounds for seeking a second opinion. In patients with impaired insulin secretion or insulin resistance, such an opinion may point out at inaccurate understanding of the disease nature and the peculiarities of its course, suggest more effective methods of sugar level control and prevention of dangerous complications. Professional services, such as MedconsOnline, can facilitate remote diabetes counseling, without visiting a doctor in person. This significantly expands the possibilities of receiving high quality medical services, since patients get a chance to communicate with world-class specialists without having to leave their city or even country.

References:

  1. Kerner, Wolfgang Pankreas-Diabetes: Häufig fehldiagnostiziert Dtsch Arztebl 2018; 115(17): [10]; DOI: 10.3238/PersDia.2018.04.27.02
  2. Dr. Judith Lorenz Pankreatogener Diabetes: Fehldiagnose mit fatalen Folgen https://www.medical-tribune.de/medizin-und-forschung/artikel/fehldiagnose-mit-fatalen-folgen
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