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Difference between revisions of "Whipple's triad"

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== Diagnosis of insulinoma is supported ==
== Diagnosis of insulinoma is supported ==


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



Latest revision as of 10:23, 28 February 2022

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

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

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 :

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 :

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

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

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