Insulinoma 2012 30 years experience with diagnosis and treatment Jan Škrha 3 rd Department of Internal Medicine, 1 st Faculty of Medicine, Charles University in Prague 27 th Symposium of the Federation of the International Danube-Symposia of Diabetes Mellitus, Budapest, 28-30th June, 2012
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Insulinoma 2012 30 years experience with diagnosis and treatment
Insulinoma 2012 30 years experience with diagnosis and treatment. Jan Škrha 3 rd Department of Internal Medicine, 1 st Faculty of Medicine, Charles University in Prague - PowerPoint PPT Presentation
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Insulinoma 201230 years experience with diagnosis and
treatment Jan Škrha
3rd Department of Internal Medicine,
1st Faculty of Medicine,
Charles University in Prague
27th Symposium of the Federation of the International Danube-Symposia
of Diabetes Mellitus, Budapest, 28-30th June, 2012
CAUSE OF HYPOGLYCEMIA1. According to pathogenesis a) decreased glucose production - lack of contraregulatory hormones - liver or kidney disease, alcohol b) increased glucose utilisation - exogenously caused (DM treatment) - endogenously caused (insulinoma)2. According to timing of the food ingestion a) fasting hypoglycemia (!!!) b) random hypoglycemia during the day - reactive (functional), postoperative
Hypoglycemia and activation of contraregulatory hormones
Algorithm of diagnosis in organic hyperinsulinismClinical suspition
Biochemical examination
Diagnosis confirmed Diagnosis unconfirmed
Topographic localisation
CT Angiography Endosonography
Localisation confirmed Localisation unconfirmed
Surgery
Insulinoma removed Insulinoma unremoved
Conservative treatment
TREA
TMEN
T
DIA
GN
OSI
S
In differential diagnosis:
HYPOGLYCEMIA FACTITIA
HYPOGLYCEMIA FACTITIA Characteristic signs:
- suspicion on insulinoma- uncertainty from clinical picture- uncertainty from laboratory findings- frequent relationship of the patient to health care providers
Attention: IATROGENIC HYPOGLYCEMIA
Insulinoma vs hypoglycemia factitia
Laboratory variable
Insulinoma Hypoglycemia factitiacaused by insulin
Hypoglycemia factitia caused by sulphonylurea
Plasma glucose ↓↓↓ ↓↓↓ ↓↓↓
Plasma insulin ↑ - ↑↑↑ ↑↑↑ ↑↑↑
Serum C-peptide ↑ - ↑↑ ↓ - ↓↓ ↑ - ↑↑
Plasma proinsulin
↑ - ↑↑ ↔ ↔
Sulphonylurea (urine)
negative negative positive
Conclusions for clinical practice
• to analyse symptoms (history !)• to confirm hypoglycemia• to elucidate cause of hypoglycemia
(confirm diagnosis)• to realize reliable treatment strategy
removing hypoglycemia (related to diagnosis and clinical state of
the patient)
Hypoglycemia is deleterious for organism and is life threatening
Collaboration
Surgery: Jan Šváb, Ladislav Krušina (†)Biochemistry: Jirina Hilgertová Marcela JarolímkováPathologist: Jaroslava DuškováMetabolic ward staff: Eva Kotrlíková Gustav Šindelka (†) Imaging: Josef Hořejš, Radan Keil