Disorders of automatic autonomic nerves

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Even as you're reading this page, many movements of muscles are going on inside your body, but you're unaware of them. Your heart muscle is squeezing down and relaxing. Your diaphragm is rising up to empty the lungs of air and relaxing to draw air in. Your esophagus is carrying food from the mouth to the stomach and, in turn, the stomach pushes it into the small intestine, which pushes it into the large intestine. All these muscle functions are under the control of nerves from the brain, and diabetic neuropathy can affect all of them. These automatic functions are called the autonomic nerves. Sensitive tests determine that as many as 40 percent of people with diabetes have some form of autonomic neuropathy.

The clinical presentation of this type of neuropathy depends upon the involved nerve. Some possibilities include

I Bladder abnormalities, starting with a loss of the sensation of bladder fullness: The urine is not eliminated, and urinary tract infections result. After a while, loss of bladder contraction occurs, and the patient has to strain to urinate or loses urine by dribbling. The doctor can easily diagnose this abnormality by finding out how much urine is left in the bladder after urinating. The treatment is to remember to urinate every four hours or take a drug that increases the force of bladder contraction.

I Sexual dysfunction, which occurs in 50 percent of males with diabetes and 30 percent of females with diabetes: Males cannot sustain an erection, and females have trouble lubricating the vagina for intercourse. (See Chapter 6 for more information on these problems.)

¡ Intestinal abnormalities of various kinds: The most common abnormality is constipation. In one quarter of all patients with diabetes, nerves to the stomach are involved, so the stomach does not empty on time. This condition is called gastroparesis. It can lead to what's called brittle diabetes, where the insulin is active when there is no food. Fortunately, a drug called metocloprimide helps to empty the stomach. A new treatment that has worked well is the implantation of a device that stimulates the stomach electrically. It greatly diminishes the symptoms. This treatment was described in a report in Diabetes Care from the University of Kansas Medical Center in May 2004.

¡^ Involvement of the gallbladder, which leads to gallstones: Normally, the gallbladder empties each time you eat, especially if you eat a fatty meal, because the substances in the bile (within the gallbladder) help to break down fat. If disease of the nerve to the gallbladder prevents it from emptying, these same substances will form stones.

¡^ Involvement of the large intestine that can result in diabetic diarrhea with as many as ten or more bowel movements in a day: Accidental loss of bowel contents can occur, and bacteria can grow abnormally in the intestine. This problem responds to antibiotic treatment. Diarrhea is treated with one of several drugs that quiet the large intestine.

¡^ Heart abnormalities: If loss of nerves to the heart occurs, the heart may not respond to exercise by speeding up as it should. The force of the heart may not increase when the patient stands, and the patient then becomes lightheaded. A fast fixed heart rate also may occur, and the rhythm of the heart may not be normal. Such patients are at risk for sudden death.

¡^ Sweating problems, especially in the feet: The body may try to compensate for the lack of sweating in the feet by sweating excessively on the face or trunk. Heavy sweating can occur when certain foods, such as cheese, are eaten.

¡^ Abnormalities of the pupil of the eye: The pupil determines the amount of light that is let in. As a result of the neuropathy, the pupil is small and does not open up in a dark room.

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