Whipple's triad

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]

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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