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Chapter 678 Which came first, the chicken or the egg? (September 9th, 28th update for subscription)

Although type [-] diabetes is caused by the body's resistance to insulin, Sun Li'en has never seen it so severe.

"This patient is most likely to have type [-] diabetes, but other factors have to be considered." Director Wu of the Department of Critical Care Medicine was not relieved that Professor Zhang readily agreed to take over the patient, but he was still a little worried He reminded, "He stayed in our ICU for three days, and yesterday he pushed down to do an abdominal CT examination. The results from the imaging department said that the patient had pancreatic atrophy, and there was a large amount of fat infiltration in the pancreas."

This is a bit interesting.Sun Li'en opened his eyes wide, and at the same time, he still had some thoughts of blaming Director Wu.This is the most important thing!What is the meaning of all the things you said earlier?
The pancreas is one of the main organs in the human body to deal with fat and glucose metabolism, and has two parts: endocrine and exocrine.The main mode of operation of the exocrine pancreas itself is to secrete pancreatic juice rich in sodium bicarbonate, trypsinogen, lipase and amylase.Pancreatic juice then enters the duodenum through the pancreatic duct, where it mixes with the predigested food to help digest protein, fat, and sugar.

The islets are the main component of the endocrine glands. A cells, B cells, D cells and PP cells together make up the islets.A cells secrete glucagon and B cells secrete insulin.These two cells are the main means of regulating blood sugar fluctuations in the body.D cells control the secretion of A and B cells by secreting somatostatin. PP cells secrete pancreatic polypeptide, and its main function is to inhibit gastrointestinal motility, pancreatic juice secretion and gallbladder contraction—it mainly interacts with the exocrine part of the pancreas.

Whether exocrine or endocrine, they are an integral part of the pancreas.The atrophy of the pancreas means that the secretion units of the endocrine department or the exocrine department are reduced, and the total amount of secretion must also decrease.

Fatty infiltration of the pancreas is another, more troublesome problem.In essence, pancreatic fatty infiltration is the same as fatty liver, which is an organ organic lesion caused by abnormal fat metabolism.Fatty infiltration can seriously affect the exocrine and exocrine functions of the pancreas, thereby seriously affecting blood sugar and protein metabolism.

Sun Lien finally understood why this patient was so valued by the intensive care medicine department.

The shrinkage and fatty infiltration of the pancreas can lead to severe diabetes and even hyperosmolar coma in patients.Severe type [-] diabetes can in turn lead to pancreatic atrophy and fatty infiltration of the pancreas.

The real headache for the Department of Critical Care Medicine lies in which of these two symptoms appeared first—is primary pancreatic atrophy and fatty infiltration leading to diabetes, or diabetes leading to pancreatic atrophy and fatty infiltration?If it is primary pancreatic atrophy, what is the cause of pancreatic atrophy?If diabetes caused the pancreas to shrink, what caused such severe insulin resistance?

Severe insulin resistance can be simply summarized clinically as a situation in which "patients need more than 200 units of insulin per day to maintain normal blood sugar". The patient in the ICU used more than 170 units of insulin in the emergency room, and his blood sugar level was still as high as 22.8mmol/L.It is almost certain that he has severe symptoms of insulin resistance.

Sun Lien followed Professor Zhang and walked towards the Comprehensive Diagnostic Center.The critical care medicine department has promised Zhang Zhifu that the patient will be transferred to the diagnosis center as soon as possible.Professor Zhang naturally happily agreed, and at the same time decided to go back and communicate with his team members about the patient's condition.

On the way back, Sun Lien was still frowning and thinking about the reasons for the symptoms of insulin resistance, and he didn’t even pick up Professor Zhang’s conversation that he planned to chat with at the beginning—Professor Zhang looked back at Sun Lien, and then looked at his frowning and thoughtful expression. expression, and smiled slightly.He didn't talk about chatting anymore, but slowed down his pace slightly while keeping quiet.

It is a great thing that young doctors are willing to think about the patient's condition.As Professor Zhang walked forward with his legs crossed, he recalled with a smile when he was young. Decades ago, he was often criticized by his tutor as "easy to distract" and "not correct".But in fact, it was just that Zhang Zhifu was too focused on thinking about the problem.

At that time...if the instructor didn't criticize me...maybe I wouldn't continue working in the clinic as if I was angry?The smile on Professor Zhang Zhifu's face was even wider, and his two crooked legs seemed to be getting stronger.Later, when I was evaluated as a professor, my mentor who had been an associate professor for almost a lifetime was actually promoted to full professor by the same batch...Professor Zhang Zhifu felt ashamed for his mentor.

"I see you've been thinking about it all the way." Although Sun Lien intends to leave enough time and space for thinking, the distance from the ICU to the comprehensive diagnostic center is always limited.When he reached the entrance of the Comprehensive Diagnostic Center, Professor Zhang Zhifu stopped, turned to look at Sun Lien and asked, "How is it? Dr. Sun, have you figured out what's wrong?"

"I still don't understand why he has such severe insulin resistance." Sun Lien stopped and replied honestly, "Generally speaking, patients with type 200 diabetes have insulin resistance, but they need to use 20 units a day. The above severe resistance...is too rare, I don’t even have a few such patients. The only one I have come into contact with is an elderly man in his 80s with a course of disease of more than [-] years.”

The patient Sun Lien mentioned was a patient he had seen when he participated in the request for consultation in the Department of Endocrinology.After the old man was diagnosed with type 18 diabetes, he took glipizide for 16 years.But there has been no review during this period, and no blood sugar has been tested.Until two years ago, the old man was re-sent to the hospital for examination because the wound was difficult to heal after the wound ulcerated.The sugar control program was also adjusted to a mixed human insulin, 18 units early and [-] units subcutaneously injected late.

"Patients with type [-] diabetes have a long course of disease and are still elderly... It is not surprising that they show resistance." Professor Zhang nodded and motioned Sun Lien to continue.

"Later, he was admitted to the hospital because of ketoacidosis, but his consciousness was still clear." Sun Lien continued, "The endocrinology department checked his IAA (insulin autoantibody) and confirmed it was positive. In the first five days, he used more than 280 IAAs every day. Units of insulin injections. Even so, his blood sugar level is still uncontrollable, and the lowest pre-meal blood sugar is 13mmol/L."

About 3% to 6% of patients with type 90 diabetes will be positive for IAA antibodies.In patients with type [-] diabetes, the detection rate of this indicator is about [-]%.It can be said that almost all patients with IAA antibody positive are type [-] diabetes.In patients with type [-] diabetes, if the IAA antibody is positive, it means that the pancreas has been mistakenly attacked by the autoimmune system.On the one hand, this attack will lead to a further reduction in the number of pancreatic islet B cells and a sharp decrease in the amount of insulin secreted by the patient.

Such patients will soon develop symptoms of insulin dependence - metformin, the most commonly used oral glucose control drug, is an insulin action sensitizer.However, under insulin dependence, this "medicine magic drug" is completely ineffective-after all, no matter how useful an insulin sensitizer is, it must have its own insulin for sensitization to work.

At the same time, there are also insulin secretagogue hypoglycemic drugs that fail.Even the DPP-4 inhibitors that are new drugs - sitagliptin, vildagliptin, saxagliptin and the like will be greatly reduced.There is also an insulin-sensitizing component to their mechanism of action.

Diabetics at this stage must inject insulin subcutaneously for life.Coupled with the original insulin resistance, the daily dosage will be desperately high.For example, this old man...during the hospitalization, the daily insulin injection reached 426U at its peak.

　The number of words is not too much, let’s do it every day and then talk about it...

　　
　
(End of this chapter)