View source for Whipple's triad

== Medical Wikipedia ==

== Whipple triad: Seen in case of  clinical presentation of pancreatic insulinoma ==

* Fasting hypoglycemia  [usually seen after fasting or intense exercise sugar level falls <55 mg/dL].
* Symptoms of hypoglycemia with low blood glucose level.
* Resolution of symptoms after glucose level is increased [administration of IV glucose]

----


Capillary blood glucose measurements not used in the hypoglycemia  evaluation process because it is not accurate.

Radiological investigation of choice now is endoscopic and/or intraoperative ultrasonography

Whipple's triad is seen in case of  insulinoma, 

Whipple triad: may be seen by hyperinsulinism not caused by insulinoma

== Neuroglycopenic symptoms ==
{| class="wikitable"
|'''Symptoms of hypoglycemia'''
|'''Neuroglycopenic symptoms'''
|-
|Sweating

Warmth

Anxiety

Tremor

Nausea

Palpitations

Tachycardia

Hunger
|Behavioral changes

Changes in vision or speech

Confusion

Dizziness

Lethargy

Seizure

Loss of consciousness

Coma
|}

== Drugs Causing Hypoglycemia ==
{| class="wikitable"
|+
!
!Drugs Causing Hypoglycemia
!
|-
!
|Insulin
!
|-
!
|Insulin secretagogues (especially sulfonylureas, meglitinides)
!
|-
!
|Alcohol
!
|-
!
|Indomethacin
!
|-
|
|Pentamidine
|
|-
|
|Quinine
|
|-
|
|Artesunate/artemisin/artemether
|
|}
Symptoms, prompting food ingestion, typically develop at a plasma glucose of 55 mg/dl (3.0 mmol/liter). At glucose levels of 55 mg/dl and lower, insulin secretion is normally almost completely suppressed.

== Diagnostic Tests ==
During an episode of spontaneous hypoglycemia measure :

{| class="wikitable"
|+
!
!During an episode of spontaneous hypoglycemia measure 
!
|-
|
|Plasma Glucose
|
|-
|
|Insulin
|
|-
|
|C-Peptide
|
|-
|
|Proinsulin
|
|-
|
|Beta-Hydroxybutyrate Concentrations
|
|-
|
|Screen For Oral Hypoglycemic Agents (Sulfonylurea and Meglitinide Drugs)
|}

== Glucagon IV : To confirm Hyperinsulinemic Hypoglycemia ==
Glucagon, 1 mg IV, should then be administered, with a rise in glucose >25 mg/dl (1.4 mmol/L) suggesting hyperinsulinemic hypoglycemia.

== Diagnosis of insulinoma is supported ==

=== Endogenous insulin suggested by: ===
if  during the hypoglycemic episode :

{| class="wikitable"
|+
!
!Endogenous insulin suggested by:
!
|-
|
|Insulin levels
|Elevated 
|-
|
|C-peptide levels
|Elevated 
|-
|
|Proinsulin levels
|Elevated 
|-
|
|beta-hydroxybutyrate
|<2.7 mmol/l, 
|-
|
|Sulfonylurea/meglitinide levels
|Undetectable
|}

* Elevated Levels - insulin, c-peptide and proinsulin levels 
* beta-hydroxybutyrate is <2.7 mmol/l, 
* Sulfonylurea/meglitinide levels are undetectable

== Exogenous insulin suggested by ==
{| class="wikitable"
|+
!
!Exogenous insulin suggested by
!
|-
|
|Insulin levels
|Increased
|-
|
|C-peptide  [ <0.2 nmol/L] levels
|Decreased
|-
|
|Proinsulin [<5 pmol/L] levels
|Decreased
|}

* Elevated Levels - insulin, 
* Low - c-peptide  [ <0.2 nmol/L]  and proinsulin [<5 pmol/L]

== Localizing studies  to evaluate for insulinoma ==
Suggested in patients with -  documented hypoglycemia with laboratory findings consistent with endogenous hyperinsulinism
{| class="wikitable"
|+
!
!investigation 
!
|-
|1
|CT  Scan, MRI Scan 
|
|-
|2
|Transabdominal and endoscopic ultrasonography,
|
|-
|3
|Nuclear medicine scans (GLP-1 receptor imaging) 
|
|-
|4
|6-[fluoride-18] fluoro-levodopa-PET-CT. 
|
|-
|5
|selective pancreatic arterial calcium injections with measurements of hepatic venous insulin levels 
|
|-
|6
|Radiological investigation of choice now is endoscopic and/or intraoperative ultrasonography
|
|}

* CT  Scan, MRI Scan , 
* Transabdominal and endoscopic ultrasonography,
* Nuclear medicine scans (GLP-1 receptor imaging) 
* 6-[fluoride-18] fluoro-levodopa-PET-CT. 
* If the diagnosis remains unclear - selective pancreatic arterial calcium injections with measurements of hepatic venous insulin levels can be performed.
* Radiological investigation of choice now is endoscopic and/or intraoperative ultrasonography
[[Category:Internal Medicine]]
[[Category:Medicine]]
[[Category:Endocrinology]]
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