الداء السكري من الألف إلى الياء
 

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 اضافة تعليق 
  
 
ينتشر داء السكري بشكل وبائي وخطير في جميع أنحاء العالم حيث تشير الإحصاءات أن هناك194 مليون مصاب  بهذا الداء في العالم ومن المتوقع أن يتضاعف هذا العدد ليصل إلى 333مليون مصاب في عام 2025،  وهذا يعني أن %6.3من التعداد العالمي سيعاني من السكري .  ولما كان زيادة الوزن والسمنة سبباً مباشراً في هذا المرض ،  فإن منع حدوث هذه المشكلة تكمن في محاربة السمنة والتي انتشرت حتى بين الأطفال والشباب،  ومن المعلوم أنه كلما بدأ هذا المرض في سن مبكرة ،  كلما ازدادت المضاعفات مثل أمراض القلب وفقدان البصر وهذا بالقطع يرهق الميزانية الصحية ويؤثر على المجتمع.
عرف مرض السكري منذ القرن السابع عشر وسمي بمرض " البول السكري " لفرط نسبة الغلوكوز glucoseالسكر الشائع  في البول وعرف بالزرب السكري  أي diabetus mellitus وتعني كلمة diabetus باليونانية نافورة أما كلمة mellitus فتعني العسل) ويأتي هذا المرض من قصور الجسم عن استعمال حاجته الحيوية الكافية من السكر ومشتقاته ، فيتراكم السكر في الكبد حيث يتحول إلى غلوكوز ويحدث فرطاً فيه في الدم إلى أكثر من 1.6ملغ في الليتر الواحد من البلازما ويبدأ بالظهور في بول المريض ، وتزداد نسبته مع ارتفاع كميته في الدم . ولكن العلاقة ليست بحتمية بين داء السكري ووجوده في بول المريض . فغالباً ما يظهر السكر في البول في حالات مرضية أخرى كالحميات والالتهابات الرئوية ، كما أن عدم ظهوره في بول المريض لا يعني أن نسبة السكر في الدم طبيعية ، والسبب في ذلك ، القصور في عملية الكليتين التي تمنع مرور السكر في البول . فلا يظهر إلا عندما تبلغ نسبته درجة عالية من الدم.
ما هو الداء السكري؟
هو مرض مزمن ناتج عن عدم قدرة غدة البنكرياس إفراز الكم الكافي من الأنسولين وقد ينتج عن عدم قدرة الجسم  على إستخدام الإنسولين بشكل سليم مما يؤدي إلى زيادة نسبة السكر في الدم. بقي سر هذا المرض مجهولاً إلى أن أتى ولس
Willis واكتشف فرط الغلوكوز في البول عام 1674 .  أما احتمالات مساهمة الخلل البنكرياسي فلم تعرف إلا في عام 1870بواسطة لانسرو Lanceraux . ومنذ العام 1877، تم تحديد البنكرياس كعضو مسؤول عن الاضطراب الذي تسبب بفرط غلوكوز الدم . وبين عام 1877و 1892ابتكر فون مرنغ Von Mering ومنكوسي Minkowski الزرب بواسطة استئصال البنكرياس . وفي سنة 1893، عزا لاغس Laguesse  لجزيرة لانغرهانس القدرة على فرز المادة التي يفتقر إليها الزرب ألا وهي  الأنسولين. insulin إلى أن نجح أخيراً ، وفي عام 1921، باحثان كنديان من جامعة تورونتو وهما بانتنغ Banting وبست Best .باستخراج الأنسولين بالرجوع إلى جزيرة لانغرهانس التي تنتجه . فاستحقا على ذلك جائزة نوبل للطب ، ومعهما ، ابتدأت المرحلة الحاسمة في تاريخ مكافحة الزرب.
أنواع الداء السكري:
هناك نوعين من داء السكري: النوع الأول
Type I غالبا ما يصيب الأطفال وهو ناتج عن عدم قدرة البنكرياس إفراز الكم الكافي من الأنسولين وعلاجه يتم عن طريق حقن المصاب بالأنسولين . النوع الثاني  Type II  في هذه الحالة لا يستطيع الجسم استخدام الأنسولين بالشكل المطلوب وعلاجه يتم بتغيير نمط الحياة وبعض الأدوية ،  وقد يحتاج إلى الأنسولين في الحالات المتقدمة . وهناك نوع ثالث يظهر في النساء أثناء الحمل فقط ويختفي مع انتهاء الحمل.
وقد يظهر الداء السكري في سياق بعض الأمراض والاضطرابات المزمنة.
عوامل الخطورة لداء السكري:
النوع الأول
Type I 
ـ عوامل وراثية.
ـ عوامل بيئية وتشمل:
ـ الإصابة بالفيروسات
ـ السموم في المواد الغذائية
النوع الثاني
Type II 
ـ زيادة الوزن والسمنة
ـ الخمول وعدم ممارسة الرياضة
ـ زيادة الدهون ونقص الألياف في الغذاء.
ـ بعض الأعراق يزيد فيها الإصابة
ـ التاريخ المرضي للأسرة
ـ العمر
ـ نقص الوزن عند الولادة
ـ كلما كان هناك أكثر من عامل للخطورة كلما زاد احتمال الإصابة بداء السكري خاصة مع تقدم السن.
الأعراض:
أعراض النوع الأول
Type I 
ـ العطش
ـ الجوع
ـ كثرة التبول
ـ فقدان الوزن
ـ الضعف العام والإرهاق
ـ زوغان في الرؤيا 50% من المصابين بالنوع الثاني من السكري لا يعلمون أنهم مصابون بهذا الداء.
أعراض النوع الثاني
Type II  :
هي نفس أعراض النوع الأول ولكنها أقل وضوحا مما قد يؤخر التشخيص بضع سنوات .
المعالجة:
العلاج الدوائي: إذا لم تتم السيطرة على ارتفاع سكر الدم عن طريق الحمية بالإضافة إلى النشاط الحركي وإزالة الوزن الزائد عندئذ لابد من اللجوء إلى العلاج الدوائي إما عن طريق:
ـ الأقراص التي تؤخذ عن طريق الفم وتساعد هذه الأقراص على زيادة إفراز الأنسولين في الجسم.  أو تساعد الأنسولين الموجود على القيام بوظائفه على أفضل وجه.  ـ الحقن تحت الجلد (بهرمون الأنسولين ) ويعطى لمرضى السكري نوع(1) الذين لا يقوم البنكرياس عندهم بإنتاج الأنسولين مطلقا وبعض حالات داء السكري نوع2 .
حاول دائما التقيد التام بالجرعة التي حددها لك طبيب الأسرة.
 هناك مجموعتان من الحبوب كلاهما يعمل بطريقة مختلفة عن الأخرى:
المجموعة الأولى :
 السلفوناي ليورياز:
هذه المجموعة من الحبوب تعمل على تحفيز البنكرياس على إنتاج المزيد من الأنسولين ويفضل استعمالها قبل وجبات الطعام(30-20دقيقة)  وقد يحدث انخفاض في مستوى سكر الدم في حالة عدم تناول الوجبات الغذائية المقررة أو في حالة الزيادة المفرطة في الجرعة الموصوفة من هذه الحبوب.
المجموعة الثانية :
بيجوانايدز:منظم السكر
تعمل هذه المجموعة على مساعدة الأنسولين الموجود في الجسم على العمل بصورة أكثر فعالية كما أنها مثبطة للشهية وتؤخذ هذه الحبوب عادة مع وجبات الطعام ومنها: الغلوكوفاج والميتفورمين. ومن آثارها الجانبية ظهور طفح جلدي ونقصان الشهية للطعام وانتفاخ البطن والغثيان والإسهال ومعظم هذه الأعراض غالبا ما تظهر مع بداية استعمال الدواء ولكنها سرعان ما تختفي تدريجيا بعد فترة من العلاج.
 ومن المهم إبلاغ الطبيب في حالة ظهور أياَ من هذه الأعراض الجانبية ..
قد يحتاج مرضى السكر الذين يستخدمون الحبوب كعلاج خافض أو منظم للسكر إلى العلاج بالأنسولين لفترات مؤقتة وذلك لعجز الحبوب عن السيطرة على نسبة السكر في الدم نتيجة لإصابات جرثومية أو مرض شديد أو إجراء عملية جراحية أو التعرض لإجهاد شديد أو المعالجة بالكورتيزون كما قد يتوقف مفعول الحبوب في بعض الحالات لعجز البنكرياس عن إنتاج أي كمية من الأنسولين وهنا لابد من إعطاء الأنسولين بطريقة الحقن اليومي.
اكارابوز(جلوكوباي):
عقار حديث يستخدم لعلاج حالات مرضى النوع الثاني من السكري خاصة الذين يعانون من ارتفاع نسبة السكر بالدم بعد الأكل ويعمل عقاراكارابوز على إبطاء امتصاص السكريات والنشويات بعد الأكل فيخفض من نسبة ارتفاع السكر بعد الوجبات..
الأنسولين:
هرمون يفرز من البنكرياس وهي أحد الغدد الصماء التي توجد بقرب الإثني عشر وتتكون من مجموعة من الخلايا كل منها مسؤول عن إفراز بعض الهرمونات أو الأنزيمات وتقوم خلايا معينة أسمها خلايا بيتا بإفراز هرمون الأنسولين.
يفرز الأنسولين عند حدوث ارتفاع في سكر الدم وينخفض إنتاجه عند انخفاض سكر الدم. أي أن مستوى سكر الدم هو الذي يحرض ويحث خلايا البنكرياس لإنتاج الأنسولين.
عمل الأنسولين:
 بعد تناول وجبة طعام فإن الجهاز الهضمي يقوم بهضم تلك المواد وعملية الهضم هي عملية تكسير الغذاء الى مكوناته الأصلية والأساسية وهي:
ـ المواد النشوية((الكربوهيدرات))تنكسر إلى جزيء صغير هو السكريات.
ـ المواد البروتينية.
ـ المواد الدهنية تنكسر الى الأحماض الدهنية وبعد ذلك لأجزاء  أصغر .
ـ يقوم الأنسولين بحث الخلايا على السماح بدخول السكر الى داخلها وخصوصا خلايا الكبد والعضلات حيث يتم تخزينه لوقت الاحتياج له .
مصادر الأنسولين:
 بشري: وهو مصنع بطرق الهندسة الكيميائية لكي يصبح مطابقا لمواصفات الأنسولين الطبيعي وهو الذي يستخدم حاليا.
حيواني: ومنه البقري .
أنواع الأنسولين: النوع الصافي أو المائي: وهو سريع وقصير المفعول،يبدأ عمله بعد نصف ساعة وأقصى مفعوله 4-2 ساعات  وينتهي في خلال  8-6ساعات.  النوع المعكر : وهو بطئ وطويل المفعول، يبدأ عمله بعد ساعتين وأقصى مفعوله 12-6ساعة ويستمر حتى 24-18ساعة.
النوع المخلوط: (70-30) صافي + معكر ، وهو معكر الشكل وله خصائص النوعين السابقين.
حفظ الأنسولين:
يحفظ في باب الثلاجة. يمكن ترك الأنسولين خارج الثلاجة لمدة لا تتجاوز 6 أسابيع من بدء الاستعمال شرط أن تكون درجة حرارة المكان لا تزيد عن 25درجة (مع مراعاة عدم اتباع هذا النظام في فصل الصيف).
 أماكن حقن الأنسولين:
الجزء الأعلى والخارجي من الذراعين.
ـ الجزء الأمامي والخارجي من الفخذين.
ـ منطقة البطن بعيدا عن السرة.
ـ الجزء الأعلى من الإليتين(المقعد).
طريقة الإعداد والحقن:
ـ اغسل يديك جيدا.
ـ ضع الزجاجة  بين راحتي يديك وحركها دائريا (دحرجة) ببطئ حتى تتأكد من خلط محتوياتها تماما ولا تقم برج الزجاجة.
ـ طهر الغطاء المطاطي للزجاجة بقطعة قطن معقمة.
ـ اسحب كمية هواء مساوية للجرعة داخل المحقنة.
ـ ادخل الإبرة خلال الغطاء المطاطي وأدفع المكبس حتى يدخل الهواء لداخل الزجاجة ، ثم ضع الزجاجة والمحقنة في الوضع الرأسي العكسي وتأكد أن رأس الإبرة مغمورا في الدواء ثم أسحب المكبس بيدك أخرى وتأكد من الحصول على الجرعة المحددة لك داخل المحقنة.
ـ تأكد من عدم وجود فقاعات هوائية وذلك برفع المكبس ثانيا والحصول على الجرعة المحددة لك بالضبط.
ـ تأكد من الجرعة مرة أخرى بعد نزع الإبرة من الزجاجة ثم أعد الغطاء على الإبرة.
ـ طهر مكان الحقن بقطن معقم.
ـ ثبت الجلد بيدك اليسرى مع رفع مساحة كافية من جلدك بين أصابعك ،وباليد اليمنى أمسك المحقنة كما تمسك القلم ثم أدخل الابرة عاموديا باستقامة داخل الجلد وتأكد من إدخال الإبرة بأكملها.
ـ ضع قطعة من القطن المعقم على موقع الإبرة خارج الجلد وأضغط القطنه على موقع الحقن لعدة ثوان.
ـ ألق المحقنة بإبرتها في علب غير قابلة للثقب بعيدا عن الأطفال ولا تستعملها مرة ثانية.
انتبه:
قم بتغيير موقع الحقن أسبوعياً وبحيث يكون هناك مسافة 2 سم بين كل حقنة والأخرى.
ـ يجب التأكد من تاريخ الصلاحية المسجل على كل عبوة.
ـ يجب التأكد أن الأنسولين الصافي يبدو صافيا كالماء والأنسولين المعكر لا توجد به تخثرات.(مواد مترسبة).
ـ اسحب الأنسولين سريع المفعول (الصافي )أولا،ثم الأنسولين بطئ المفعول(المعكر).
ـ يتم عادة تقسيم جرعة الأنسولين المحسوبة لك في اليوم كالتالي 2/3 الجرعة صباحا - 1/3الجرعة مساء.
ما هي المضاعفات المزمنة التي يمكن أن يحدثها داء السكري؟ 
نود الآن التحدث عن بعض مضاعفات السكري التي قد تصيب بعض أعضاء الجسم على المدى الطويل إذا لم يعالج المرض أو إذا لم تتم السيطرة على مستوى السكر في الدم ، وهي العين ،القلب و الأوعية الدموية ، الأعصاب ، الكلى.
ـ مشاكل الرؤية: يؤثر مرض السكر تأثيراً مباشرا ًعلى العدسة والشبكية منها : تكوين المياه البيضاء في العدسة ومنها أيضاً تأثيره على الأوعية الدموية الموجودة في الشبكية ويعتبر داء السكري من أهم أسباب فقدان البصر في الأشخاص الذين تتراوح أعمارهم من  (74-20)سنة.
اعتلال الأعصاب:
يؤثر مرض السكري على الأعصاب على المدى الطويل مما يؤدي إلى:
 ضعف أو فقدان الإحساس بالقدمين والشعور بالألم مما يتعذر على المريض الشعور بالجروح أو الالتهابات الجلدية التي قد تحدث في القدمين علما بأن شفاء الجروح والالتهابات لدى مريض السكري أمر صعب  بحد ذاته مما يؤدي إلى بتر الساقين لا سمح الله إذا لم يتم علاجه مبكرا. ألم وضعف بالعضلات .  الضعف الجنسي عند الرجال ، ضعف المثانة والأمعاء مصحوب بنوبات إسهال شديدة. ولكن من الممكن تفادي والوقاية من هذه المضاعفات عن طريق الحمية ، الرياضة ، السيطرة على مستوى السكر في الدم وإتباع إرشادات طبيب الأسرة بدقة .
ـ اعتلال القلب والأوعية الدموية: الأشخاص المصابين بالسكر أكثر عرضة للأزمات القلبية بمعدل  (4-2)مرات ومعرضين لانسداد أو تصلب الأوعية الدموية الكبيرة مثل:
1- شرايين الدماغ مما يؤدي إلى جلطة دما غية.
2- شرايين القلب مما يؤدي إلى جلطة قلبية أو ذبحة صدرية.
3- شرايين الساقين مما يؤدي إلى ضعف الدورة الدموية وحدوث غرغرينا القدم.
- اعتلال الكلى: يؤثر مرض السكر على الكلى مما يحدث ترسب تدريجي في الشعيرات الدموية للكلية مما يؤدي إلى تصلبها وأيضاً يحدث انخفاض في نسبة ترشيح الفضلات الخاصة بالجسم، وتجمعها داخل الجسم.   وكنتيجة لهذه التغيرات تبدأ الكلية بطرح مواد يحتاج إليها الجسم مثل بروتينيات الدم وبعض الأحيان يتم توقف عمل الكلية مما يؤدي إلى حاجة المريض إلى الغسيل الكلوي أو عملية زرع كلية (راجع السكري واعتلال الكلى).
السكري واعتلال الكلية:
يعتبر السكري من أهم العوامل المسببة لعجز الكلى النهائي ، حيث حوالي %30-20من مرضى السكري بنوعيه الأول والثاني قد ينتج لديهم اعتلال الكلية السكري مع مرور الوقت. العلامة المبكرة لاعتلال الكلية السكري هو ظهور كمية بسيطة ولكن غير طبيعية من الزلال (البروتين) في البول بما يسمى البول الزلالي الصغري  (
microalbuminuria)و تقدر كمية الزلال في البول في هذه الحالة بأكثر من 30مجم في ال24 ساعة . وفي هذه الحالة اذا لم يتم التدخل العلاجي السريع فان %80من مرضى السكري سيزيد لديهم معدل الزلال البولي الى ان يصل المصاب الى مرحلة الاعتلال الكلوي السكري  حيث يزيد كمية الزلال في البول الى أكثر من 300مجم في ال24 ساعة بما يسمى المتلازمة الكلائية ومنها الى القصور الكلوي وبذلك يصلوا الى مرحلة العجز الكلوي النهائي.
ولكن لماذا يؤثر السكري على الكليتين؟
 ان الكليتين تعملان كمصفاة مكونة من مجموعة من وحدات التصفية التي تصفي الدم من السموم والفضلات . يدخل الدم الى الكليتين عبر أوعية دموية صغيرة تسمى بالأنابيب الشعرية ، فاذا كنت مصابا باعتلال الكلية السكري فان هذه الأنابيب قد تصاب بالانسداد وبذلك لا يتم تصفية الدم بشكل صحيح وتصبح راشحة فتنفذ منها البروتينات والمواد الغذائية التي يجب أن تبقى بالدم لكنها تذهب الى البول مما ينتج عنه الزلال البولي الصغري الذي قد يتدرج الى مرحلة عجز الكلية النهائي. تضرر الكلية بالسكري لا يظهر الا بعد مرور وقت طويل من الاصابة بالسكري في غالب الأحيان خاصة في مرضى النوع الأول (حوالي 15-10سنة من الاصابة ) ، حيث أن الكلية تعمل بجهد ووقت مضاعفين للتخلص من جميع السموم من الدم ولكن كلما مر الوقت كلما زاد تضرر الكلية حتى تصبح غير قادرة على تحمل العبء ونتيجة لذلك تبدأ أولى أعراض العجز عليها. ومن حسن الحظ ، هناك فحوصات يمكن اجراؤها لاكتشاف المرض في مراحله الأولى . ان بعض الدراسات بينت ان اكتشاف الزلال البولي الصغري بالاضافة لكونه العلامة المبكرة لاعتلال الكلية السكري فهو أيضا علامة كبيرة قد تدل على احتمال اصطحاب المرض لآثار في القلب والأوعية الدموية . لذلك اذا أكتشف وجود زلال بولي صغري في البول هذا يحثنا على عمل فحص شامل للقلب والأوعية الدموية والعمل على معالجة جميع العوامل المساعدة لظهور أمراض القلب المصاحبة مثل تخفيض مستوى الدهون في الدم ، ايقاف التدخين ، تخفيض ضغط الدم المرتفع ، وهكذا. هناك أيضا دراسة بينت أن تخفيض مستوى الكلسترول في الدم قد يؤدي الى تخفيض مستوى الزلال في البول والسيطرة على مضاعفات السكري للكلى.
كيف يتم الكشف عن الزلال البولي الصغري ؟
ومتى يجب الكشف عنه؟ بمجرد اكتشاف مرض السكري النوع الثاني فانه يجب فحص البول لوجود الزلال الصغري أما النوع الأول من مرض السكري وهو النوع الذي يظهر عادة في الأطفال قبل سن البلوغ فانه يتم فحص البول للزلال بعد التشخيص بخمس سنوات.
هذا الفحص البولي يجب أن يتكرر مرة سنويا والطريقة الصحيحة لتجميع البول لفحصه من أجل الزلال يفضل أن تكون عند أول بول في الصباح نتيجة لاختلاف كمية الزلال في البول على مدار اليوم . اذا تم اكتشاف زلال البول لأول مرة يفضل على الأقل تجميع البول وفحصه على فترتين خلال 6-3 أشهر للتشخيص النهائي للمريض على أنه يعاني من الزلال البولي الصغري كمرحلة أولى لاصابة الكلى بالضرر من السكر .ويجب أيضا عند اكتشافه القيام بعمل فحص مخبري لوظائف الكلى وقياس مستوى الكلسترول بالدم.
ما هو علاجه؟
كما ذكرنا فان ظهور الزلال البولي الصغري يدل على أن هناك تغييرات تحدث في الأوعية الدموية التي تقوم بتصفية الدم والتخلص من الفضلات ومنها ارتفاع ضغط الدم في هذه الأوعية فالعلاج الموصوف هو مثبط انزيم أنجيوتنسين كونفيرتينج (
ACE)  والذي يستخدم عادة في علاج ضغط الدم المرتفع سيقوم بتخفيض ضغط الدم من خلال ايقاف الأنزيمات التي تضيق الأوعية الدموية. مثال لهذه العقاقير (الكابوتين، الرينيتيك) . فعندما يخفض ضغط الدم في هذه الأوعية يقل تضرر الكلية فبالتالي تقل كمية البروتينات التي تترشح من الدم الى البول الى حد كبير. الخطوة الأخرى في العلاج هي التقليل من الملح (الصوديوم والفوسفيت). وأخيرا التقليل من البروتينات الحيوانية مثل اللحوم وغيرها بنسبة 0.6جم/كجم/يوم ولكن يجب أن يكون تحت نظام غذائي صحي باشراف اختصاصي تغذية حتى لا يحصل وهن وضعف في العضلات. 
ما هي الوقاية منه؟
 ان الخطوة الأساسية للوقاية من تضرر الكلية من داء السكري هو السيطرة على مستوى سكر أو غلوكوز الدم بحيث يكون وقت الصيام بمستوى بين 120-80مجم /دل وبعد الأكل يكون أقل من 140مجم/دل.
السيطرة على ضغط الدم المرتفع فيجب على مريض السكري أن لا يزيد ضغط دمه عن 130/85فاذا كان ضغط الدم أعلى من ذلك فانه سوف يسرع من الاضرار بالكلى.
وأخيرا يجب الفحص الدوري السنوي للزلال البولي الصغري لاكتشافه مبكرا وعلاجه.
موات القدم السكرية  ليس هبة من السماء بل نتاج الأرض
تنتشر قرحة القدم بنسبة 10-4من مرضى السكري،ويحدث البتر لدى السكريين أكثر  من 30-10مرة من عامة الناس يسبب الداء السكري 8من10 من البتور غير الرضية كما أن الوقوع السنوي المتعلق بالعمر لبتور الطرف السفلي غير الرضية في السكريين يتراوح من1000/13.7-2.1 شخص.
وتتراوح وفيات بعد البتر بين %13الى%40 خلال سنة واحدة و%35 الى%65 خلال ثلاث سنوات و%39 إلى %80خلال خمس سنوات- فهي أسوأ من السرطانات .
 الأسباب المرافقة لقرحة القدم:
قرحة / \بتر سابق.
ـ الاعتلال العصبي :
 ـ حسي حركي، حذاء سيء، المشي حافيا، سقوط حوادث، مواد ضمن الحذاء.
ـ الآليات الإحيائية:- تحدد حركة المفصل- بروزات عظمية- تشوه القدم اعتلال العظم والمفصل- شثن.
ـ مرض وعائي محيطي:
ـ الوضع الاقتصادي الاجتماعي: منزلة اجتماعية منخفضة- عوز بالرعاية الصحية- عدم المطاوعة (\الإهمال)\- نقص الوعي.
يوجد اتفاق عام على أن أكثر عوامل الخطورة أهمية في إحداث القرحة هي وجود الاعتلال العصبي المحيطي الحسي الحركي.
تراوح الانتشار المقدر للاعتلال العصبي المحيطي بين 30الى %70،تبعا للمجموعات السكانية المدروسة وحسب التعاريف والمعايير التشخيصية- إن %90-80 من قرحات الأقدام المذكورة في دراسات عينات أفقية سرع بحدوثها الرض الخارجي  الحذاء غير المناسب عادة.
إن حوالي %100-70من القرحات يوجد فيها علامات الاعتلال العصبي المحيطي مع درجات من المرض الوعائي المحيطي.
وفي دراسة معتمدة على الجمهور وذات عينات أفقية كانت نسب آفات الاعتلال العصبي،والآفات الإقفارية العصبية،والآفات الإفقارية هي %55و%34 و%10على التوالي- وكانت نسبة %1فقط من القرحات اعتبرت أنها لا تعود للداء السكري.
أكثر من ذلك كانت في هذه الدراسة نسبة %47من القرحات معروفة سابقا من قبل الأطباء.
يعرف المرض الوعائي المحيطي في الأشخاص السكريين بأعراضه وعلاماته بما في ذلك مشعر كاحل عضد أقل من 0.9-0.8وقدرت نسبة انتشاره من %20-10في دراسات مختلفة.
يتنوع طيف إصابات القدم في مناطق متنوعة من العالم ويعود ذلك إلى الفروق في الظروف الاجتماعية الاقتصادية، ومعايير العناية بالقدم ونوعية الأحذية- فالأحذية غير المناسبة أو إذا لم تستعمل بشكل كافي، أو الافتقار للأحذية هي أكثر الأسباب الرضية المسببة لقرحة القدم- يمكن الوقاية من الكثير من قرحات القدم بالفحص الدوري للقدم، وتسهيل الحصول على العناية بالقدم والأحذية المناسبة. لكن لغاية اليوم لا يحصل مرضى الداء السكري على فحص دوري لأقدامهم و على العناية المناسبة لأقدامهم.
تشترك عوامل متعددة بتأخير عملية الالتئام الطبيعي للقرحة، عند السكريين وهي الإنتان، ونقص التروية،والاعتلال العصبي،والأمراض المرافقة. وهذا يستدعي تعدد المداخلات وعادة مقاربة فريق متعدد الاختصاصات. كما إن المداخلات على قرحة القدم والمتابعة اللصيقة من الممكن أن تخفض نسب البتور لغاية %85-49.
من المهم جدا ملاحظة أن معلوماتنا حول الفيزيولوجيا المرضية تتضمن عواقب على المعالجة وقبول الوسائل الجراحية والعلاجية الأخرى.
فالبتور تكون نتيجة مباشرة للخرافات المستمرة غير الصحيحة ودوام الأفكار الخاطئة الشائعة:
ينتج الغانغرين عن مرض الأوعية الدقيقة.
لا تلتئم الشقوق الجراحية على القدم السكرية و لا تعمل المجازات بشكل جيد كما في المرضى غير السكريين.
مثال: كان يعتقد لقرون أن المشكلة الرئيسية في الداء السكري هو، مرض الأوعية الصغيرة ، والى حد ما هو تعبير ضعيف معروف قديماً كتفسير للعديد من مضاعفات هذا الداء، متضمنا قرحات القدم. لكن يرجح أن هذا المصطلح يؤثر عكسيا على العناية بمرضى قرحات القدم السكرية حيث يقدم عدمية العلاج في مقاربة هذه الجروح المزمنة.
 
لذلك ما تحقق في سنوات قليلة مضت هو فكرة أن اعتلال الأوعية الدقيقة الساد الحقيقي في الأطراف السفلية لمرضى الداء السكري غير صحيح أو غير نوعي لأجل مرضى الداء السكري وهذا جلب فائدة مثيرة في كيفية إعادة التروية الوعائية للقدم السكرية التي تمت مراجعتها وممارستها.
تسمح الفحوص غير الباضعة والاستخدام الواسع لتصوير الشرايين الظليل بكشف وإصلاح الإصابات الهامة وعائيا.إن المقاربات داخل الوعاء مناسبة أحيانا لكن الخيار الجراحي من أجل إعادة البناء الوعائي يكون ممكنا في كل حالة تقريبا ينتج عن إعادة البناء الوعائي في %80-75إنقاذ الأطراف خلال خمسة سنوات.
الفيزيولوجيا المرضية:
إن %85من كل بتور الأطراف السفلية العائدة للداء السكري تسبقها عادة قرحة القدم.
والعوامل الأكثر أهمية المؤدية إلى حدوث قرحات القدم هي:
اعتلال الأعصاب المحيطية ورضوض القدم الصغيرة وتشوهات القدم. يفقد كثير من الأشخاص المصابين بالداء السكري الحس في أقدامهم،وقد تحدث التشوهات دون أن يدركوا الرضوض الصغيرة المتكررة أو الأذية الممزقة للجلد أو المدمرة للقدم.
خفض نسب البتور:
يمكن خفض نسب البتور من %85-50إذا أنجزت الاستراتيجيات التالية:
ـ فحص دوري لقدم وحذاء المريض في الزيارات الدورية.
ـ العناية الوقائية بالقدم والحذاء في الأقدام المعرضة للخطورة ،معالجة الأقدام بالأحذية الطبية، التثقيف.
ـ المعالجة الباكرة من قبل فريق متعدد الاختصاصات.
ـ التشخيص الباكر لأمراض الأوعية المحيطية والتداخل الوعائي.
ـ المتابعة المستمرة للمرضى الناقهين من قرحات القدم حديثا.
ـ تسجيل البتور وقرحات القدم.
يستطيع مدراء البرامج عبر إدراكهم وجهودهم:
ـ تحسين الداء السكري.
ـ وتحسين نتائج المرضى.
ـ والاستخدام الأمثل للموارد.
كما أن التكاليف العالية للقرحات والبتور،مقابل التكاليف المنخفضة نسبيا،لرعاية الأقدام ستجعل التكاليف المنفقة فعالة و مؤثرة.
الســـكر
 الحملي:
 هو السكر الذي يظهر لأول مرة أثناء الحمل.
تقريبا %5-3من النساء الحوامل يشخص لديهم داء سكري حملي هؤلاء النسوة وعائلاتهم لديهم أسئلة كثيرة حول هذا الاضطراب.
ـ ما هو الداء السكري الحملي؟
ـ من يصاب به؟
ـ كيف يشخص لدي السكر الحملي؟
ـ ما تأثير السكر على الحامل؟
ـ ما تأثير السكر وهل سيؤذي طفلي؟
ـ هل ساصاب به مستقبلا؟
ـ كيفية المعالجة؟وغيرها من الأسئلة؟
من أجل هذه الأسئلة وغيرها يجب أن يفهم الناس وخاصة الأمهات ما هو السكري الحملي وكيفية العناية بالأم وجنينها.
السكري الحملي مرض قديم قدم الانسان فقد عرفه اليونان والفراعنة وتحدثوا عنه.
كيف يحدث؟
إن المشيمة هي مسكن الجنين ومصدر غذائه كما انها مصدر الكثير من الهرمونات التي تلعب دور بالحفاظ على الحمل.
ولكن وللأسف هذه الهرمونات تلعب دور المعاكسة لعمل الأنسولين مثل/الاستروجين-البروجسترون-اللاكتوجين المشيمي-الكورتيزول وغيرها..
هذه الأفعال المضادة تظهر تقريبا بالاسبوع 24-20من الحمل ومع نمو المشيمة أثناء الحمل تزداد نسبة هذه الهرمونات وتزداد المقاومة للأنسولين ورغم زيادة إفراز خلايا البنكرياس للأنسولين لكن هذه الزيادة تكون غير كافية لردع هرمونات المشيمة مما يؤدي الى ما يسمى بالسكري الحملي .
من هن النساء المعرضات للإصابة؟
إن النساء ذوات الخطورة عالية الإصابة بالداء السكري هن:
ـ النساء مع بدانة .
ـ وجود قصة عائلية لداء السكري.
ـ قصة حمول متعددة مع وفيات متعددة .
ـ  سوابق حدوث استسقاء أمينوسي أثناء الحمل.
ـ قصة ولادة أو ولادات مع أطفال كبيري الحجم.
ـ حوامل بأعمار فوق 35سنة.
ـ الحوامل مع وجود الداء السكري الحملي؟
يتم تشخيص السكري الحملي بإجراء اختبار تحمل السكر.
الإجراء:قبل إجراء الاختبار يجب أن يكون هناك نظام غذائي لمدة 3 أيام تتناول فيه الحامل على الأقل 150غ كربوهيدرات في كل يوم أو أكثر.
مثال:صحن معكرونة صغير-قطعتان فواكه-100غ خبز-3 كؤوس حليب -أو ثلاث كؤوس لبن أو أكثر يوميا.
يوقف تناول الطعام قبل عشر ساعات من الاختبار ويسمح بتناول الماء فقط صباحاً.
ـ يسحب عينة من الدم.
ـ يعطى بعد ذلك 100غ من السكر.
ـ ثم يقاس سكر الدم بعد ساعة- ساعتين-ثلاث ساعات- من الإعطاء في حال إجراء الاختبار على البلاسما الوريدي.
ـ اذا كان سكر الدم على الريق 105مغ/دل الطبيعي80مغ/دل.
ـ اذا كان سكر الدم بعد ساعة 190مغ/دل الطبيعي125مغ/دل
ـ اذا كان سكر الدم بعد ساعتين 165مغ/دل الطبيعي105مغ/دل
ـ اذا كان سكر الدم بعد ثلاث ساعات 140مغ/دل الطبيعي 90مغ/دل
في حال وجد قيمة أو أكثر يشخص داء سكري حملي في حال الاختبار على دم الحامل:
ـ سكر الدم على الريق 90مغ/دل وأكثر الطبيعي أقل من 90مغ /دل
ـ سكر الدم بعد ساعة 165مغ/دل وأكثر الطبيعي أقل من 160 مغ/دل.
ـ سكر الدم بعد ساعتين 145مغ /دل وأكثر الطبيعي 140 مغ/دل.
ـ سكر الدم بعد 3ساعات 125مغ/دل أو أكثر الطبيعي أقل من 120مغ/دل.
ـ هذا الاختبار يجري بين الاسبوع 28-24من الحمل لكل حامل أما في حال وجود عوامل خطورة يجري هذا الاختبار بإعطاء /50غ/ من السكر ويجري قبل الاسبوع/13/ من الحمل.
يكون اختبار السكر إيجابي في:
ـ الداء السكري نمط/1/ أو نمط.2
ـ الداء السكري الحملي.
ـ أمراض الكبد الخطيرة.
ـ فرط نشاط الغدة الدرقية.
ـ كوشينغ.
ـ ورم القواتم.
ـ وقد يكون اختبار السكر سلبي أو قليل في حال وجود أمراض معوية- قصور الكظر-بعض أورام البنكرياس.
كيف يؤثر السكر على الحمل؟
مفتاح العلاج ومنع التأثيرات ومنع الاختلاطات هو التشخيص المبكر للسكر والحمية والعلاج الواجب.
تعتبر الأشهر الثلاثة الأولى من الحمل مرحلة تشكل الأعضاء الجنينية لذا في حال ارتفاع سكر الدم الذي يؤدي الى طرح مادة الكيتون بسبب تحلل الدهون المشاهد عند الأمهات مع ضبط سيء لسكر الدم وعبور هذا الكيتون عبر المشيمة الى الجنين يؤدي الى مشاهدة تشوهات ولادية.
كذلك وجود الكيتون في الثلث الثاني من الحمل وعبوره الى الجنين يؤدي الى عدم نمو جيد للدماغ عنده مسببا نقص ذكاء لاحق.
المشاهد بكثرة زيادة ضخامة الجنين والآلية هي ارتفاع سكر الدم عند الام الذي يؤدي الى عبوره عبر المشيمة الى الجنين مما يسبب إفراز الأنسولين الجنيني كمية السكر المزدادة لدى الجنين تختزن كشحوم وهذه تسبب زيادة حجم الأعضاء أي الدماغ وتسبب ما يسمى  
Macrosomia   أي الجنين الكبير.
كذلك يؤدي الداء السكري غير المضبوط الى تكون مشيمة صغيرة متليفة تحتوي الكثير من الخثرات مما يؤدي الى نقص أكسجة المشيمة وحدوث نقص أكسجة مزمن عند الجنين.
كذلك يؤدي فرط سكر الدم عند الام وبالتالي عند الجنين الى تأخر نضج الرئة عند الجنين.
فرط سكر الدم المزمن عند الام يسبب اضطراب في الشوارد وأهمها البوتاسيوم الذي يؤدي الى اضطرابات التقلصية القلبية ونقص الأكسجة قد يسبب وفاة الجنين.
كيفية التعايش مع مرض السكري:
 على الرغم من أنه لا يوجد علاج جذري لاستئصال مرض السكري ولكن بإستطاعة مريض السكر العيش حياة طويلة وطبيعية. ولكن أهم نقطة لتحقيق ذلك وهي التحكم في نسبة السكر في الدم بالنسب الطبيعية وممكن تحقيق ذلك عن طريق.
ـ الغذاء بطريقة صحيحة .
ـ مزاولة الرياضة( مع إستشارة طبيب الأسرة) .
ـ المحافظة على الوزن المثالي
ـ المحافظة على تناول العلاج (الحبوب) أو الأنسولين.
الغذاء المتوازن ( الحمية)
ـ تناول ثلاث وجبات في اليوم تقريبا في نفس الوقت ولا تحاول حذف أي وجبة.
ـ تناول أنواع متعددة من الطعام ويشمل ذلك الغذاء المحتوي على كمية كبيرة من الألياف   مثل : الخضروات والفواكه والحبوب.
ـ حاول تناول أقل من (%30) من السعرات الحرارية خلال اليوم من الدهون.
ـ أستشر طبيب الأسرة ليتم تحويلك إلى أخصائي التغذية لعمل الحمية الغذائية الخاصة بك.
الحمية الخاصة بمرضى السكري:
إن هذه الحمية عبارة عن نظام غذائي متوازن خاص بمريض السكري وبما يتناسب واحتياجاته وتعتمد على معرفة مسبقة لما يأكه عادة وعلى ما يحبه ويفضله من أطعمة وعلى نوعية النشاط والمجهود الجسدي اليومي. والهدف منها هو تنظيم مستوى السكر في الدم خلال اليوم بحيث تتناسب كمية الأنسولين (سواء الذي يفرزه الجسم أو الذي يحقن) مع مستوى السكر في الدم (والذي يعتمد على ما يتناوله الشخص من مواد سكرية أو نشوية).
تجنب الاكثار من الملح:
حيث يتسبب في تراكم الماء في الجسم وربما ارتفاع ضغط الدم وهو أحد مضاعفات مرض السكر، لذا عليك الإقلال من استخدام الملح أثناء الطهي ولا تضع ملح على المائدة وتجنب بقدر الإمكان تناول الأطعمة المحفوظة والمأكولات السريعة حيث أنها تحتوي على الكثير من الملح.
أساسيات الحمية
تناول الأطعمة الغنية بالألياف
فالألياف تساعد على الحفاظ على نسبة الجلوكوز (السكر) والدهون في الدم في المعدل الطبيعي كما تمنع الإمساك، فعليه من الأفضل زيادة كمية الأطعمة التي تحتوي على الألياف لذلك:
تناول النخالة والشعير والرز البني وغير المقشور والفاصوليا المجففة والبازلاء والعدس والخبز المصنوع من الحبوب الصافية.
أكثر من تناول الخضروات سواءً نيئة أو مطبوخة وبدلاً من عصير الفواكه تناول الفاكهة طازجة وبقشرها كلما أمكن.
الألياف ممكن أن تسبب غازات بالبطن إذا تم أكل كميات كبيرة منها وفي وقت قصير، ولكن مع مضي الوقت يقل هذا الإحساس.
تناول الأطعمة قليلة الدهون
فالإكثار من الدهون يؤدي إلى أمراض القلب والأوعية الدموية وهي أكثر الأمراض التي تنتج عن مرض السكر تعقيداً وخطورة، لذا قلل من تناول اللحوم الحمراء وأستبدلها بالسمك والطيور وإذا أردت أكل اللحوم الحمراء فاستخدم اللحوم الخالية من الشحم، أستخدم للطبخ طريقة الشواء أو الخبز في الفرن أو البخار بدلاً من القلي.
قم بإزالة الدهون من اللحم وجلد الطيور قبل الطهي وتجنب إضافة الدهون عند الطهي (السمن أو الزيت والزبد الطبيعي والصناعي /مارجارين) أو عند تقديم الطعام مثل الزيت أو صلصة/"سوس" السلطات.
تجنب تناول الأطعمة الغنية بالدهون مثل المكسرات  واللحوم الباردة والنقانق والسجق.
تناول القليل من الآيس كريم والجبن والكريمة وبما يتناسب ونظامك الغذائي وتناول الحليب القليل أو الخالي الدسم بدلاً من الحليب الكامل الدسم.
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