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 type of diabetes mellitus, that is, identifying the causes of its development, that mistakes often occur.

What are the forms of diabetes?

When immune processes go wrong, leading to damage of insulin-producing cells, type 1 diabetes develops. This is a rather rare form. Most people (about 90%) with impaired glucose metabolism have type 2. 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 cause, other specific types of this disorder are distinguished, such as certain genetic defects, pregnancy, etc.

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

When diabetes mellitus 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 is made. Pancreatic diabetes 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.

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 disorder 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?

The most frequent (over 78%) cause of pancreatic diabetes is a chronic inflammatory process (chronic pancreatitis), especially its calcifying variant.

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.

If there is a strong reason to suspect pancreatic diabetes, 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 can not 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 cause 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, pancreatic diabetes 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 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.

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 diabetes mellitus, 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 manifestations of glucose metabolism disorder.

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 diabetes mellitus is very important. Timely initiation of a diet, drug therapy, as well as lifestyle correction 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 cause of the disease.

References:

Kerner, Wolfgang

Pankreas-Diabetes: Häufig fehldiagnostiziert

Dtsch Arztebl 2018; 115(17): [10]; DOI: 10.3238/PersDia.2018.04.27.02

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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