If a patient with diabetes regularly takes insulin or sugar-reducing tablets prescribed by a doctor, and also follows a rational diet, then he may feel fit and relatively healthy for a long time. However, the violation of the diet and taking drugs, as well as stress and alcohol abuse can cause a decrease in the body’s resistance to carbohydrates, and as a result – the occurrence of a decompensated state.
There are concomitant diseases related to the competence of a cardiologist, oculist, urologist, dentist, etc. The surgical complications of diabetes are also frequent. They can be divided into three groups. The first group includes transient complications of diabetes mellitus, it is: pseudoperitonitis, or a false “acute abdomen”, and acute gastric bleeding. The second group includes acute purulent-inflammatory diseases of the skin and subcutaneous base. And finally, the third group of surgical complications is caused by a violation of the process of regeneration or healing of wounds.
Pseudoperitonitis
A patient who is in a state of precoma or coma often has certain digestive disorders. In this case, it is extremely important to differentiate diabetic pseudoperitonitis from a true “acute abdomen”: if you perform an operation in the state of precoma or coma, then in the vast majority of cases it can result in the death of the patient. Although it is not always easy to separate these two states, there are a number of symptoms that allow you to recognize a reliable picture of the disease.
Thus, a gradual onset of the disease is characteristic of pseudoperitonitis, while for a true “acute abdomen” it begins suddenly and sharply. Peritonitis, which is a consequence of diabetes mellitus, is most common in young and middle-aged people, the true disease can occur at any age. The body temperature of a patient with diabetes mellitus is normal or low, there is a strong rapid heartbeat (tachycardia), a drop in blood pressure (hypotension), noisy deep breathing, and a reduced tone of the eyeballs. A different picture emerges with true peritonitis: normal or elevated body temperature, moderate increase in pulse rate or slowing down (bradycardia), blood pressure, as a rule, remains unchanged, breathing can be increased, the tone of the eyeballs is not affected.
Patients with diabetes mellitus have a pronounced thirst and dry mouth, almost always there is the smell of acetone from the mouth, as a rule, there is a “splash noise” in the abdominal cavity, while all the above symptoms are less characteristic when diagnosing true peritonitis. The characteristics of the skin of patients in general and of the face are directly opposed: in diabetics, the skin is dry and the skin of the face is hyperemic (with redness), in the absence of diabetes mellitus – the skin is moist and pale.
There are certain differences in the state of the abdomen, the general state and consciousness of patients with pseudoperitonitis and true. In the first case, abdominal distention is observed, as a rule, in the epigastric region, abdominal pains are “diffuse” in nature; excitement is quickly replaced by general weakness; characteristic confusion of consciousness, often – sopor. Abdominal bloating in patients with true peritonitis is rarely observed (if there is a dynamic intestinal obstruction), abdominal pain is clearly localized; the general condition worsens gradually, the patient is in clear consciousness. Finally, glucose indicators in diabetic patients are always high (23.8 – 33.3 mmol/l), while with the picture of a true “acute abdomen” they remain normal (4.4 – 6.6 mmol/l) .
In addition to hyperglycemia, the number of leukocytes also increases (up to 80–90–103 at 1 μm/l) and the level of residual nitrogen (over 4.9 mmol / l). And pH values, on the contrary, fall to 7.1 – 6.38. Significant changes occur in the urine of patients with diabetes mellitus: protein, blood elements, granular cylinders appear, because the kidneys are exposed to toxic damage by the type of acute glomerulonephritis.
False peritonitis is quite a serious complication, it contributes to any purulent process in the soft tissues, as well as pneumonia and gangrene of the lower extremities. There are several causes of pseudoperitonitis:
1) increasing the concentration of blood enzymes (diastase and amylase);
2) irritation of the autonomic nerve plexus of the gastrointestinal tract;
3) exacerbation of chronic pancreatitis;
4) irritation of the solar plexus with diabetic decay products.
As a result, peritoneal capillary toxicosis develops, which is manifested by the occurrence of point hemorrhages.
If a patient with diabetes is noted: cyanosis, the facial features are sharpened, the extremities get cold, there is a frequent threadlike pulse (up to 120 beats per minute) and exhausting vomiting – in this case, the patient needs urgent surgeon advice. Patients with diabetes are shown intensive insulin therapy, in which the symptoms of “acute abdomen” may disappear within a few hours. If diabetes mellitus decompensation has disappeared (the patient is removed from the coma, hyperglycemia is reduced, dehydration and ketoacidosis are eliminated), but nevertheless there is inflammation of the peritoneum, then such patients need surgery.
Acute gastrointestinal bleeding
This condition is characterized by weakness, headache, the smell of acetone from the mouth, sudden heart palpitations (with a weak filling pulse) and hiccups. The patient experiences a feeling of heaviness in the epigastric region and feels pain, which has a diffuse character without precise localization. Blood pressure and body temperature remain within the normal range.
However, the general condition of the patient is assessed as quite difficult: he is restless, often there is an arrhythmia (cardiac arrhythmia) in the form of ventricular extrasystole and atrial fibrillation. An electrocardiogram reveals signs that are characteristic of hyperkalemia. As with diabetic pseudoperitonitis, “splashing noise” and flatulence (bloating) are characteristic in the abdominal cavity, while the abdominal muscles are not tense.
Of the external signs should be noted dry tongue with brown bloom and blush. Complete the picture vomit color of coffee grounds with a putrid odor and tarry stools.
If the above symptoms are observed in patients suffering from diabetes, then hemorrhagic gastritis, characteristic of diabetics, can be differentiated from a peptic ulcer by means of X-ray or fibrogastroscopic examination, as well as laboratory tests. High concentrations of blood and urine contain glucose and acetone.
Thus, gastric bleeding, like pseudoperitonitis, is one of the manifestations of diabetes mellitus decompensation. There are certain reasons that cause hemorrhagic gastritis:
1) an excess of histamine (tissue hormone) and its accumulation in the blood;
2) increased permeability of the gastric vessels due to a large amount of histamine;
3) erosion of the gastric mucosa caused by increased production of gastric juice (as a reaction to the formation of a contra-insulin hormone – glucagon);
4) the presence of increased acidity (hyperacidity), resulting in reduced blood clotting.
If you suspect hemorrhagic gastritis, it is necessary to urgently conduct intensive insulin therapy and achieve compensation of metabolic processes. Such complications of diabetes mellitus — gastric bleeding of ketacidotic origin — are to be monitored by both the surgeon and the endocrinologist. Therapeutic measures ultimately boil down to the immediate elimination of ketoacidosis, especially since the symptoms of diabetic pseudoperitonitis can often be added to the symptoms of gastric bleeding.
Acute inflammatory diseases of the abdominal organs in diabetes mellitus
Acute surgical conditions, such as acute cholecystitis, cholecystopancreatitis, acute appendicitis, in patients with diabetes mellitus, as a rule, turn into peritonitis or other equally serious complications. Compared with people who have normal carbohydrate metabolism, such complications occur more frequently in diabetics.
As a rule, within 6 to 8 hours, the precomatose or comatose state occurs, and after 12 to 18 hours from the appearance of the first signs of the disease, the acute surgical symptoms in such patients appear quite sluggish. Thus, during surgery, local as well as widespread peritonitis, often abscesses, is detected in the affected organ, while the symptoms of an acute abdomen can be expressed only slightly.
On the other hand, atypical manifestation of one or another acute surgical pathology in patients with diabetes mellitus leads to gangrenous modified gallbladder, appendix, destructive pancreatitis, etc.
In contrast to persons who have normal carbohydrate metabolism, in patients with diabetes mellitus, the vascular pathology of the organs of the organ acts as the primary cause of damage to the abdominal organs (and not a bacterial infection, as in the first case). This pathology is manifested, in particular, by atherosclerosis and increased blood clotting (hypercoagulation). Therapeutic measures for such diseases should be carried out, taking into account the following factors: symptoms of surgical pathology and diabetes mellitus, biochemical blood test and patient’s individuality (i.e., the possibility of his body).
Only in the presence of the first degree of the so-called “mutual complication syndrome” (i.e., establishing priority in the elimination of certain patient conditions) – there is compensation for diabetes mellitus and obvious symptoms of acute cholecystitis – is anti-inflammatory treatment carried out, and the general tactic is active-waiting.