Name
INSULINOMA
DESCRIPTION
DETAIL
CAUSES OF HYPOGLYCEMIA : 1. DRUGS - INSULIN , SULPHONYLUREAS , ETHANOL , SOMETIMES PENTAMIDINE, QUININE RARELY SALICYLATES, SULPHONAMIDES, ACE INHIBITORS, PROPRANOLOL & OTHERS 2. ENDOGENOUS HYPERINSULINISM - INSULINOMA - OTHER BETA CELL DISORDERS - SECRETAGOGUE ( SULPHONYLUREA) - AUTOIMMUNE ( AUTOANTIBODIES TO INSULIN, INSULIN RECEPTOR , BETA CELLS ? ) - ECTOPIC INSULIN SECRETION 3. CRITICAL ILLNESSES - HEPATIC , RENAL & CARDIAC FAILURE - SEPSIS - STARVATION & INANITION 4. ENDOCRINE DEFICIENCIES - CORTISOL , GROWTH HORMONE - GLUCAGON & EPINEPHRINE ( TYPE I DIABETES ) 5. NON BETA CELL TUMORS - FIBROSARCOMA - MESOTHELIOMA - RHABDOMYOSARCOMA - LIPOSARCOMA & OTHER SARCOMAS - HEPATOMA - ADRENOCORTICAL TUMORS - CARCINOID TUMOR - LEUKEMIA - LYMPHOMA - MELANOMA - TERATOMA 6. DISORDERS OF INFANCY & CHILDHOOD - TRANSIENT INTOLERANCE OF FASTING - INFANTS OF DIABETIC MOTHERS( HYPERINSULINISM ) - PERSISTENT HYPERINSULINEMIC HYPOGLYCEMIA OF INFANCY - INHERITED ENZYME DEFECTS 7. POSTPRANDIAL - REACTIVE ( AFTER GASTRIC SURGERY ) - ETHANOL INDUCED - AUTONOMIC SYMPTOMS WITHOUT TRUE HYPOGLYCEMIA 8. FACTITIOUS - INSULIN - SULPHONYLUREASOTHER TESTS : * PLASMA / SERUM INSULIN LEVELS - ELEVATED * MOST RELIABLE TETST IS - FAST UPTO 72 HRS WITH SERUM GLUCOSE , C-PEPTIDE & INSULIN MEASUREMENT EVERY 4 - 6 HRS. IF AT ANY POINT PT BECOME SYMPTOMATIC OR GLUCOSE LEVELS ARE PERSISTENTLY < 40 MG / ML, THE TEST SHOULD BE TERMINATED. THE RATIO OF INSULIN TO GLUCOSE IS < 0.3 ( IN MG / ML ) . * SERUM PROINSULIN LEVELS - NORMAL IN EXOGENOUS INSULIN / HYPOGLYCEMIC AGENTS USERS & ELEVATED( UPTO 80% ) IN INSULINOMA ( NORMAL VALUE 10-20% ) * C-PEPTIDE LEVELS - LOW IN EXOGENOUS INSULIN USERS & ELEVATED IN INSULINOMA * ANTIBODIES TO INSULIN - POSITIVE IN EXOGENOUS INSULIN USERS * SULPHONYLUREA LEVELS IN SERUM OR PLASMA * FACTITIOUS SULFONYLUREA OR MEGLITINIDE - ELEVATED INSULIN & C-PEPTIDE LEVELS BUT NORMAL PROINSULIN LEVELS. * ULTRA SOUND ABDOMEN, CT ABDOMEN, CELIAC ANGIOGRAPHY, AORTOGRAPHY ARE FREQUENTLY INSENSITIVE & MAY LOCALIZE ABOUT 60% OF INSULINOMAS. * ENDOSCOPIC ULTRA SOUND OR INTRAOPERATIVE ULTRA SOUND * TRANSHEPATIC PORTAL VENOUS SAMPLE MAY LOCALIZE OCCULT TUMORS. * LOCALIZATION MAY BE DONE BY COMPARISION OF INSULIN LEVELS IN THE RT. HEPATIC VEIN FOLLOWING SELECTIVE INFUSION OF THE INTRAPANCREATIC ARTRIES WITH CALCIUM GLUCONATE
TYPENOTES
RISK FACTORS: Older than 40, MEN 1 syndromeAPPROPRIATE HEALTH CARE Treatment is primarily surgical; medical treatment for surgically incurable lesions GENERAL MEASURES β’ Closely observe for severe hypoglycemic symptoms β’ Attempt to increase glucose levels β’ Attempt to decrease insulin levels β’ Keep a ready glucose source available SURGICAL MEASURES β’ Enucleation if tumor is superficial β’ Partial pancreatectomy if tumor is deep-seated or invasive β’ Mechanical ablative techniques (hepatic arterial embolization for refractory metastases) ACTIVITY Avoid exercise DIET Frequent high carbohydrate meals and snacks DRUG(S) OF CHOICE . To decrease insulin secretion . Diazoxide 100-150 mg po q8h (3-8 mg/kg daily in 2 or 3 divided doses) . Octreotide acetate (long acting analog of somatostatin); 50-100 mcg SQ bid, increase as needed to control symptoms . To increase glucose levels . Oral or IV glucose . IM or SQ glucagon . For metastatic disease . Streptozocin plus doxorubicin . Fluorouracil ALTERNATIVE DRUGS . Octreotide acetate. Continue treatment until surgery or lifelong if tumor is unresectable. . Dacarbazine (DTIC, 5-dimethyltriazenoimidazole-4-carboxamine) for metastatic disease . To increase glucose levels . Corticosteroids . Propranolol . Phenytoin PATIENT MONITORING Watch for recurrence of hypoglycemic symptoms POSSIBLE COMPLICATIONS . From surgery . Pancreatitis . Pancreatic leaks . Fistulae . Peritonitis . Abscess . Pseudocysts EXPECTED COURSE/PROGNOSIS Excellent if tumor solitary, benign, and completely resected
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
ULTRA SOUND WHOLE ABDOMEN - FEMALE, COMPLETE BLOOD COUNT, SERUM INSULIN ( FREE ), CT SCAN ABDOMEN, MRI, BLOOD SUGAR ( RANDOM )