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🏥 | What is "IgG4-related disease" that is easily mistaken for cancer?International attention


Photo: Even if there is a tumor, it may be an IgG4-related disease rather than cancer (C) Nikkan Gendai

What is "IgG4-related disease" that is easily mistaken for cancer?International attention

 
If you write the contents roughly
In 19, an international diagnostic standard was created.
 

There is a tumor, it may be cancer ...When I was told that, I would like to keep in mind that it is easy to be mistaken for cancer. → Continue reading

 Daily Gendai Healthcare

We will deliver the medical and health articles of the evening paper "Daily Gendai". From everyday health laws to the latest medical information, all articles are based on interviews with doctors and specialists.


Wikipedia related words

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Diabetes test

Diabetes test(Tonyobyo no Kensa)Diabetes mellitusDescribes the main tests used for diagnosis and judgment of therapeutic effect.Here, we first specify the diagnostic criteria and then outline the tests that are often used.

Diagnosis of diabetes

JapanNow, we will use the 2010 diagnostic criteria from the Japan Diabetes Foundation.By the way, in the United States, considering the simplicity of the test, only fasting blood glucose is emphasized, whereas in Japan and Europe, there is a difference in that postprandial blood glucose is included in the diagnostic criteria.

Criteria for glucose tolerance test
Normal typeBorderline typeDiabetic type
Fasting blood glucose(Less than)
IFG
(that's all)
Blood glucose level after 2 hours(Less than)
IGT
(that's all)
Judgment conditionHungry and after 2 hours
Both
or or
  • Fasting blood glucose 110-125 mg / dlImpaired Fasting Glucose, IFGThe 75-hour value of the 2 g oral glucose tolerance test is 140-199 mg / dl.Impaired glucose tolerance; Impaired Glucose Tolerance, IGTCall.
Judgment criteria
  1. If there is a blood glucose level of 126 mg / dl or more on an empty stomach, it is judged to be diabetic without a glucose tolerance test.
  2. Fasting blood glucose or 75gOral glucose tolerance testDiagnosis is usually made twice, but if it is diabetic type once or twice, it is diagnosed as diabetes.
  3. Shows "diabetic type", and only once when blood glucose level is 200 mg / dl or more, typical symptoms such as dry mouth, polydipsia, polyuria, diabetic retinopathy are present, or HbA1c is 6.5% or more. Diabetes is diagnosed by the judgment of.
    • IGT is a condition that can be called a "prediabetes army", and the difference from clinical diabetes is whether or not there are complications described later.However, it is now known that IGT patients also develop complications such as neuropathy, myocardial infarction, and arteriosclerosis, and the meaning of clearly distinguishing them from diabetes is diminishing (DECODA study).[1]Funagata Town Study).
During pregnancy

Another gestational diabetes mellitus (GDM) during pregnancy[2]Judgment criteria apply.

  • Diagnosis is made when one or more of the following criteria are met in 75g OGTT.
  1. Fasting blood glucose level ≧ 92 mg / dL (5.1 mmol / l)
  2. 1 hour value ≧ 180mg / dL (10.0 mmol / l)
  3. 2 hour value ≧ 153mg / dL (8.5 mmol / l)

After diagnosing diabetes, the next thing you need to do is figure out what kind of diabetes you have and think about treatment based on that.To do these.It is important to understand the cause and trigger of diabetes, the degree and duration of hyperglycemia, and the degree of complications.

Causes and Triggers of Diabetes

First, we will diagnose from the etiology such as whether it is type 1 diabetes, type 2 diabetes, or secondary diabetes.Most cases are type 2 diabetes, but this should only be done by diagnosis of exclusion.As a procedure, we first suspect type 1 diabetes.Basically, type 1 diabetes and type 2 diabetes show completely different clinical features, so it seems easy to distinguish them.However, since there is a disease type called SPIDDM (slow progressive IDDM) that seems to be type 2 diabetes, anti-GAD antibody should be measured and denied at least once.If this is neglected, the treatment policy will be wrong.It also searches for the presence or absence of diabetes-inducing diseases.There is no time to worry about this process.Hepatic diabetes (performed in the liver)Glycogen synthesis-GlycogenolysisDiabetes mellitus associated with disruption of glycemic control due to pancreatic diabetes (pancreas)Beta cellsDiabetes mellitus associated with disruption of glycemic control due to insulin secretion from the body), infectious diseases, and malignant tumors are relatively easy to test.If the facilities are scarce at the clinic, etc., when you are diagnosed with diabetesComplete medical checkup,Cancer screeningShould be recommended.Also, even if it is not scrutinized, keep in mind the endocrine diseases.Graves' disease,Acromegaly,Cushing's syndromeAre well known as the causes of secondary diabetes.It is often suspected by basic physical examination such as palpation of the thyroid gland or looking at the face.What is important is that secondary diabetes can be completely cured by treatment of the underlying disease. If type 1 diabetes and secondary diabetes can be denied, it is considered to be type 2 diabetes, which is a lifestyle-related disease.

Even in type 2 diabetes, by asking about the background of the onset, it is often clear what was wrong with the lifestyle.Disorders in lifestyle may be due to eating habits, exercise habits, or alcohol, or if you have a family history of diabetes, it may be due to your constitution, or due to excessive intake of soft drinks or sugar.PET bottle syndromeIt will be easier to improve your lifestyle if you confirm that you have not fallen into such a situation.

Degree and duration of hyperglycemia

These can be grasped by creating subjective symptoms and medical history.Confirm dry mouth, polydipsia, and polyuria (especially the number of nocturia) as subjective symptoms.Next, listen to the progress of your weight.We will look at changes centered on the maximum weight, the weight at the age of 20, and the current weight.If you lose weight without treatment, you often have advanced diabetes.If these signs are present, the duration of hyperglycemia is very long and the presence of complications such as small angiopathy is suspected.Since there is often no nephropathy if there is no retinopathy empirically, there is also a method of giving priority to fundus examination if no obvious renal disorder is found.Creating a medical history, such as suspected diabetes or pointed out urinary sugar in a medical examination, is often useful for future treatment.

Degree of complications

If you try to do this firmly, you need to confirm all the complications of diabetes, and it is difficult for the current medical system to confirm all at once in outpatient departments.

Large angiopathy
Large angiopathy, specificallyMyocardial infarction,Cerebrovascular disease ThePrediabetesIt is known to appear from the time of.Basically, check the degree of arteriosclerosis.Hearing of carotid, abdominal, and femoral arteries, and palpation of the popliteal, dorsalis, and posterior tibial arteries are indicators of arteriosclerosis.In addition, patients with borderline diabetes and diabetes develop painless myocardial ischemia, so even if there is no episode.electro-cardiogramShould be enforced.The appearance of small blood vessel disorders is easy to predict because it is often parallel to changes in blood glucose levels, but macroangiopathy can occur at any time when glucose tolerance is impaired, so the degree of arteriosclerosis is regularly grasped. Must.It is often done in recent years.This is a test to measure IMT (carotid intima-media complex thickening).It is a test that measures the maximum thickened part of the carotid artery and 1 points 3 cm to the left and right of it, and uses the average value as an index.Often there is a lesion in the carotid branch. If the IMT exceeds 1.1 cm, there are signs of arteriosclerosis and may require consultation with neurosurgery. IMT is an easy-to-use index because it correlates well with the occurrence of macroangiopathy and its therapeutic effect is visible.Of arteriosclerosisRisk factorNeedless to say, remove.
Small angiopathy
As an evaluation of neuropathy, vibration sensation of the lower limbs,Deep tendon reflexThe (DTR) patellar tendon reflex (PTR) and Achilles tendon reflex (ATR) are indicators.A foot inspection is performed at that time.fundamentallyNeuropathyJust think that there is.A symptom that is easily noticed is numbness in the legs.Evaluation of nephropathy is performed by urinalysis.If urinary protein is positive, it is almost certain that there is nephropathy, but even if it is negative, nephropathy cannot be denied.Microalbumin is measured, and if it is 30 to 300 mg / gCr or more, early nephropathy occurs.Blood pressure control at the time of early nephropathy, specifically renal protective effectACE inhibitorCan be prevented from progressing by administering.The therapeutic effect is determined by the effect of blood pressure and the decrease in proteinuria.For retinopathy, a fundus examination is performed at an ophthalmologist.A symptom that is easily noticed is blurred vision.A fundus examination should be done annually, even if no abnormalities are seen.The appearance of retinopathy strongly suggests that nephropathy will progress in the future.A fundus examination should be done before treatment for diabetes.It is known that as retinopathy progresses, retinopathy progresses when the blood glucose level is rapidly improved.If there is advanced retinopathy, it is said that it can be treated relatively safely if it takes about 1 months to reduce HbA3c by 6%.

Blood sugar related tests

Blood glucose level
Blood sugar levels can easily fluctuate by eating or exercising.Measured without eating after waking up in the morningFasting blood glucoseAnd you can measure at any timeBlood sugar from time to timeIs the subject of evaluation.For regular load blood glucose (blood glucose measured by eating a normal meal), one hour after the start of the meal (with a chopstick)postprandial gIt is said that lycemia 1hr (PPG1hr) often peaks, and it is considered promising.[3].
Hemoglobin A1c(HbA1c)[4]
It is said to represent the average blood glucose level for the past 1-2 months. HbA1c less than 6.5% is good control[5]..It is also known that there is a great deal of fluctuation due to eating habits, and even if there is an episode such as overeating recently, the diagnosis of diabetes may be false positive.It is known to occur lower in patients with liver cirrhosis and hemolysis, in which case glucoalbumin may be substituted. HbA1c is said to be normal at 5.8% or less and diabetic at 6.5% or more, but in the diagnosis based on OGTT, it is often overlapped because it is widely distributed in normal type, borderline type, and diabetic type, and borderline type. It is said that it cannot be used for diagnosing diabetes or denying diabetes. If the value is greater than 5.8%, it is necessary to suspect prediabetes and scrutinize it.
For conversion to average blood glucose
Is reported to be appropriate[6].
Glycoalbumin
It is said to represent the average blood glucose level for the last two weeks. It has the advantage of being able to see recent changes in blood glucose levels over HbA2c, but it is different from HbA1c.Clinical researchHas not been confirmed to be effective.AlsoNephrotic syndromeLow price, etc.CirrhosisIn such cases, the value becomes high and does not correlate with blood glucose fluctuation.
1,5-Anhydroglucitol(1,5-AG)
1,5-AG is a substance ingested from food.It is found in a certain amount in the body, but in diabetes, it is excreted together with glucose in the urine, so the blood concentration decreases.Reflects blood glucose levels over the last few days.
Located on the side chain of proteins in the bloodAmino groupOf glucoseAldehyde groupBound non-enzymatically (Maillard reaction,Amadori rearrangement), Produces saccharified protein.This saccharified protein has side chain bondsFructoseIt is also called fructosamine because of its structure.Fructosamine is a saccharified protein of all proteins. (Glycoalbuminalbumin, HbA1chemoglobinSaccharified protein) Currently, it is not covered by insurance in Japan and is rarely used in clinical practice.

A test to measure insulin secretory capacity

Insulin secretion index (II)
75gOral glucose tolerance testThe value obtained by dividing the increase in blood insulin 30 minutes after loading by the increase in blood glucose level is called the insulin secretion index.This is an indicator of the initial secretion of additional insulin secretion.Early to early secretions of diabetes tend to be impaired.A diabetic type has this value less than 0.4.PrediabetesIt is said that patients with this value less than 0.4 are more likely to develop diabetes.
II = ⊿ Blood insulin level (30 minutes value-0 minutes value) (μU / ml) / ⊿ Blood glucose level (30 minutes value-0 minutes value) (mg / dl)
Blood C-peptide
It is used as an index of insulin secretory capacity.In patients who are using insulin as a treatment, even if blood insulin is measured, the injected insulin is also measured, which is meaningless.Also, in patients with anti-insulin antibodies, blood insulin measurements do not accurately reflect the amount of effective insulin in the body.C-peptideIt is,pancreasIs a by-product of making insulin and reflects the amount of insulin your body is making (not injected).When the fasting blood C-peptide is 0.5 ng / ml or less, it is considered to be insulin-dependent.
Urinary C-peptide
By measuring C-peptide in urine accumulated for 24 hours, insulin secretory capacity is measured more accurately than blood C-peptide.Because it requires cold storage, it can only be tested during hospitalization, but it is the most reliable test for insulin secretory capacity. If it is 20 μg / day or less, it is considered to be insulin-dependent.
Glucagon load test
The most accurate and insulin secretory test used in clinical studies.Give insulinhormoneIsGlucagonAnd observe the change in C-peptide level before and after injection.
HOMA-β

A test to measure insulin resistance

75g Oral Glucose Tolerance Test (75g OGTT)
It is a test showing impaired glucose tolerance at the time of the test.GlucoseAfter drinking the solution containing 75g, check the progress of blood glucose level, urinary sugar, blood insulin level, etc. over time.This 2-hour blood glucose level of OGTT is adopted as a domestic diagnostic standard.In addition, fluctuations in blood glucose level and insulin from 0 to 30 minutes are known as insulinogenic indexes in Japan and are useful for evaluating insulin secretory capacity (not an international consensus). At 75gOGTT, the peak is different from that of PPG1hr because the peak shifts to the later time (glucose solution has a slow absorption speed).It is said that it should not be performed in diabetic patients with subjective symptoms because it may lead to severe hyperglycemia.On the contrary, HbA1c is the best indication when it is 5.8% to 6.5%.
Blood insulin
Surprisingly, it is an indicator of insulin resistance. Type 1 diabetes is extremely rare or may not be detectable. In the early stages of type 2 diabetes, it is usually high because it lowers blood sugar that is too high.in recent years,metabolic syndromeIt is also attracting attention in relation to (not included in the diagnostic criteria).If the blood insulin concentration in the early morning fasting is 15 μU / ml or more, obvious insulin resistance is considered.To see the insulin secretory capacity, calculate the insulin secretory index.At that time, since the blood insulin concentration is necessary, it can be said to be a secretory capacity test, but it alone is an index of resistance.
HOMA-R
When the fasting blood glucose level is 140 mg / dl or less, it is a simple index that can be performed even in an outpatient setting, which is said to correlate well with other insulin resistance values.Calculated by fasting blood glucose and fasting blood insulin levels.
HOMA-R = fasting insulin level (μU / ml) x fasting blood glucose level (mg / dl) / 405
If it is 2.5 or more, insulin resistance is present, and if it is 1.6 or less, it is normal.However, it cannot be used in patients undergoing insulin treatment.
Glucose clamp method
How much insulin can lower a person's blood sugar by injecting glucose and insulin to help maintain a steady state of blood sugar, ieInsulin resistanceTo measure.It is said to be the most accurate in measuring insulin resistance, but it is not often done in general hospitals because it is complicated.
Indicator of metabolic syndrome
It is said that there are many cases of insulin resistance in visceral fat obesity, hypertension, hypertriglycerid (TG)emia, and hypoHDLemia.

Examination of lipid metabolism

Ketone bodies
Acetoacetic acid,3-Hydroxybutyric acid,acetoneThese three substances are collectively called ketone bodies.Ketone bodies are used by the body when glucose cannot be used as an energy source due to insufficient insulin action.fatIs generated as a result of trying to convert.It can be examined by a urine or blood test.Ketoacidosis is an important test for type 1 diabetes because it is more likely to occur in type 1 diabetes.also,Sick day(A general term that refers to days when you are suffering from a disease other than diabetes such as an infectious disease and cannot eat), because ketone bodies tend to increase, when you get sick due to type 1 diabetes, the condition is measured. You can evaluate it yourself (if you have ketone bodies, you should inject more because your insulin injection is below demand).Recently, there is also a self-monitoring blood glucose meter that can measure blood ketone bodies.
Triglyceride (TG)
Neutral fatTends to rise in the blood due to increased production in the liver and decreased utilization in peripheral tissues.

Diagnostic imaging

Various diagnostic imaging is performed for complications.

Fundus photo
Diabetic retinopathyTaken to evaluate.
Ultrasonography
Due to diabetic nephropathy by abdominal ultrasonographykidneyConfirm the morphological change of.
very rarelyPancreatic cancerMay be the cause of type I diabetes.
CirrhosisMay reduce glucose metabolism and lead to secondary diabetes.
Carotid artery echo by cervical echoArteriosclerosisTo evaluate.This often reflects systemic arteriosclerosis.

Source

[How to use footnotes]
  1. ^ Nakagami T. et al: Diabetologia, 47: 385-394, 2004,
  2. ^ Abnormal glucose metabolism during pregnancy and diagnostic criteria (revised August 27, 8) Japan Diabetes and Pregnancy Society
  3. ^ Takashi Kadowaki: Diabetes UP-DATE, 1999; Hanefeld: Diabetologia, 1996
  4. ^ As of 2010, the HbA1c value (Japan Diabetes Society value) used in Japan is about 1% lower than the HbA0c value (National Glycohemoglobin Standardization Program value) used in countries other than Japan. Is.
  5. ^ Diagnostic criteria for metabolic syndrome The University of Tokyo School of Medicine Diabetes Metabolism Internal Medicine 11th Laboratory Home Page
  6. ^ Diabetes Care 31: 1473-1478, 2008

References

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