| Abstract|| |
Diabetic autonomic neuropathy gives rise to varied manifestations in the gastrointestinal tract i.e. gastropathies, nocturnal diarrhoea, oesophageal dysmotility, constipation and gallbladder dysfunction, being consequence of vagal neuropathy leading to reduced G.I. Motility. Gallbladder involvement in diabetic autonomic neuropathy is in the form of high incidence of gall bladder stones and a significant increase in gall bladder volume with poor concentration and poor visualization, with lack of symptoms of gallbladder disease. The present study concluded that gall bladder disease is more prevalent among type 2 diabetics. Diabetics with autonomic neuropathy tend to have larger gall bladders with poor contraction in response to fatty meals (due to vagal neuropathy), thus predisposing these patients to various forms of gall bladder disease.
Keywords: Diabetes Mellitus, Gall Bladder, Ultrasound
|How to cite this article:|
Singh S, Chander R, Singh A, Mann S. Ultrasonographic evaluation of gall bladder diseases in diabetes mellitus type 2. Indian J Radiol Imaging 2006;16:505-8
|How to cite this URL:|
Singh S, Chander R, Singh A, Mann S. Ultrasonographic evaluation of gall bladder diseases in diabetes mellitus type 2. Indian J Radiol Imaging [serial online] 2006 [cited 2014 Aug 20];16:505-8. Available from: http://www.ijri.org/text.asp?2006/16/4/505/32257
| Introduction|| |
Asymptomatic period of hyperglycemia, being on an average of 5 to 7 years, many individuals tend to have complications at the time of diagnosis, which are macrovascular.
Amongst various types of neuropathy, autonomic neuropathy, although a well recognized complication, has been given less attention. In addition to manifestations in many other systems, autonomic neuropathy gives rise to varied manifestations in the gastrointestinal tract i.e. gastropathies, nocturnal diarrhoea, oesophageal dysmotility, constipation and gallbladder dysfunction, being consequence of vagal neuropathy leading to reduced G.I. motility. Duration of diabetes mellitus is positively related to prevalence of gallbladder disease, the type of therapy has no association and the fasting plasma glucose concentration is inversely associated with gall bladder disease.
Gallbladder involvement in diabetic autonomic neuropathy is in the form of high incidence of gall stones and a significant increase in gall bladder volume with poor concentration and poor visualization, with lack of symptoms of gallbladder disease. The present study aims to find out the prevalence of gallbladder disease in type 2 diabetes, correlation of gallbladder disease with duration of diabetes and comparison of gallbladder dysfunction in patients with and without autonomic neuropathy as well as normal individuals.
- To study the prevalence of gallbladder disorder in type 2 diabetes mellitus.
- Correlation of gall bladder disease with duration of diabetes mellitus.
- Comparison of gall bladder diseases in patients with/without autonomic neuropathy as well as normal individuals.
| Material and Methods|| |
The present study was carried out in the Department of Radiodiagnosis, Govt. Medical College/GND Hospital, Amritsar. The type 2 diabetic patients were selected at random from outpatient clinics and in-patient services at Guru Nanak Dev Hospital and Guru Teg Bahadur Hospital Complex. For the diagnosis and classification of diabetes, ADA criteria of fasting glucose > 126 mg/dl was used4. The present study included 50 diabetic subjects, out of which 25 had autonomic neuropathy and 25 were without autonomic neuropathy. 25 healthy, non diabetic, and matched (for age and sex) subjects without any gallbladder disease comprised the control group.
Ultrasound examination of abdomen was performed after 12 hours of overnight fasting in the morning using real time scanner with 3.5 megahertz transducer to record.
i) Size of gallbladder
ii) Gallbladder wall thickness
iii) Presence of stones, sludge or carcinoma of gall bladder
Gall bladder volume has been calculated using ellipsoid method5.
V= 6 (LxWxH)
Where L = Length
W = Width of the gallbladder
H = Height
Gall bladder motility was observed by measuring fasting gallbladder volume and post meal gallbladder volume one hour after giving fatty meal i.e. (bread with butter 40 gm).
The percentage of gallbladder contraction was calculated by the formula6.
Fasting Gall bladder volume - Post fatty meal gall bladder volume x 100
Fasting gall bladder volume
The results have been compiled, tabulated and statistically analyzed.
| Results|| |
Mean age of diabetics with autonomic neuropathy (AN) was 62 years, of diabetics without AN was 54.56 years and of controls was 58.2 years.
48% of diabetics with autonomic neuropathy were males and 52% were females, 56% of diabetics without autonomic neuropathy were males and 44% females, while in control group males were 46.6% and females 53.3%.
The mean duration of diabetes in patients with autonomic neuropathy was 13.6 years and in diabetics without autonomic neuropathy was 6.04 years. Thus autonomic neuropathy becomes more prevalent with increasing duration of diabetes.
Percentage of gallbladder disease among various study group is shown in table no. I.
It is to be noted that all patients having ultrasonographic evidence of cholecystitis had associated cholelithiasis [Figure - 1]. Thus prevalence of gall bladder disease is significantly higher in diabetics with autonomic neuropathy as compared to controls but there was no significant difference in the prevalence of gall bladder disease among diabetics with and without autonomic neuropathy.
From table II, it is concluded that fasting gall bladder volume of diabetics with autonomic neuropathy was higher than that of controls [Figure - 2] and the value was found to be highly significant (p <0.001). Fasting gall bladder volume of diabetics with AN was higher than those without AN, the difference was not statistically significant (p >0.10).
From table III, it is clear that the percentage of contraction of gall bladder is reduced in diabetics as compared to controls [Figure - 3] as it is further reduced in diabetics with autonomic neuropathy, but the difference was not statistically significant in any of the groups.
Among 13 out of 50 diabetics who had ultrasonographic evidence of gall bladder disease only 46.13% had subjective symptoms of the disease, while 53.8% had clinically silent disease.
Overall prevalence of somatic neuropathy among diabetics was 70%. All the diabetics having autonomic neuropathy had somatic neuropathy, implying that somatic neuropathy always precedes development of autonomic neuropathy.
| Discussion|| |
The similarity between the gastrointestinal symptoms following surgical vagotomy and those complicating diabetes mellitus has strongly suggested that latter are due to involvement of autonomic nervous system in diabetic neuropathy.
Various studies,, conducted in the past as shown in Table IV have shown a positive correlation between gall bladder disease and diabetes. The present study too has shown a positive correlation between the two. It has almost confirmed that there is increased prevalence of gall bladder dysfunction among diabetics and diabetics tend to have larger gall bladders with reduced responsiveness to meals which might lead to stasis of bile and development of complications like sludge, cholelithiasis and cholecystitis. Although exact pathophysiologic basis of gall bladder dysfunction in diabetes is yet not clear, motor abnormalities of gall bladder function is one of the proposed mechanisms. These motor abnormalities include large size and impaired contractility of gall bladder due to vagal visceral neuropathy.
Gall bladder emptying was found to be impaired more among diabetics having autonomic neuropathy. Clinical implication of the study could be due to reduce mortality and morbidity from various complications.
Since gall bladder abnormalities usually remain clinically silent among diabetics, patients may suddenly present with catastrophic complications like acute cholecystitis requiring emergency cholecystectomy. Due to increased mortality and morbidity associated with emergency surgery in diabetics, prophylactic cholecystectomy may be advisable in asymptomatic diabetics when evidence of non-functioning gall bladder is demonstrated on ultrasonography.
| References|| |
|1.||Haffner SM, Diehl AK, Valdez R et al. Clinical gall bladder disease in NIDDM subjects - relationship to duration of diabetes and severity of glycaemia. Diabetes Care 1993; 16: 1276-84. |
|2.||Chapman BA, Chapman TM, Frampton CM et al. Gall bladder volume: comparison of diabetics and controls. Dig Dis Sci 1998; 43: 344-348. |
|3.||Gitelson S, Schwartz A, Fraenkal M et al. Gall bladder dysfunction in diabetes mellitus; the diabetic neurogenic bladder. Diabetes 1963; 12: 308-312. |
|4.||Report of Expert Committee on the diagnosis and classification of Diabetes Mellitus. Diabetes Care 1997; 20: 1183-97. |
|5.||Raman PG, Patel A, Mathew V. Gall bladder disorders and type 2 diabetes mellitus - a clinical based study. JAPI 50: 887-889, 2002. |
|6.||Gaur C, Mathur A, Aggarwal A et al. Diabetic autonomic neuropathy causing gall bladder dysfunction. JAPI 2000; 48: 603-605. |
|7.||Atkinson M, Hosking DJ. Gastrointestinal complications of diabetes mellitus. Clinics in Gastroenterology 1983; 12: 633. [PUBMED] |
|8.||Jorgensen T. Gall bladder stones in a Danish Population. Relation to weight, physical activity, smoking, coffee consumption and diabetes mellitus. Gut 30: 528-34, 1989. |
|9.||Del Favero GM, Caroli A, Meggiato T et al. Natural history of gall stone in NIDDM. A prospective 5 year follow up. Dig Dis Sci 1994; 39: 1704-07. |
A-I, Medical College Campus,Govt. Medical College, Amritsar - 143001
[Figure - 1], [Figure - 2], [Figure - 3]
[Table - 1], [Table - 2], [Table - 3], [Table - 4]