Insulinoma differential diagnosis: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
No edit summary
 
(13 intermediate revisions by 5 users not shown)
Line 1: Line 1:
__NOTOC__
__NOTOC__
{{Insulinoma}}
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Insulinoma]]
{{CMG}}; {{AE}} {{ADS}}
{{CMG}}; {{AE}} {{ADS}}


==Overview==
==Overview==
Insulinoma must be differentiated from other diseases that cause features of [[hypoglycemia]] like [[altered mental status]]/[[confusion]], profuse [[sweating]] and visual disturbances ([[Blurred vision|blurring]]/[[diplopia]]). These are classified on the basis of [[laboratory]] findings into exogenous [[insulin]], [[oral hypoglycemic agent]]<nowiki/>s (e.g. [[sulphonylurea]]<nowiki/>s), [[nesidioblastosis]], insulin autoimmune hypoglycemia.
Insulinoma must be differentiated from other diseases that cause features of [[hypoglycemia]] like [[altered mental status]]/[[confusion]], profuse [[sweating]] and visual disturbances ([[Blurred vision|blurring]]/[[diplopia]]). These are classified on the basis of [[laboratory]] findings into exogenous [[insulin]], [[oral hypoglycemic agent]]<nowiki/>s (e.g. [[Sulphonylurea]]<nowiki/>s), [[Nesidioblastosis]], insulin autoimmune hypoglycemia.


==Differentiating insulinoma from other Diseases==
==Differentiating insulinoma from other Diseases==
*Insulinoma must be differentiated from other diseases that cause features of [[hypoglycemia]]. These are classified on the basis of [[laboratory]] findings.
Insulinoma must be differentiated from other diseases that cause features of [[hypoglycemia]]. These are classified on the basis of [[laboratory]] findings.


===Differentials for [[Hypoglycemia]] on the basis of Laboratory findings<ref name="pmid19088155">{{cite journal| author=Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER et al.| title=Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline. | journal=J Clin Endocrinol Metab | year= 2009 | volume= 94 | issue= 3 | pages= 709-28 | pmid=19088155 | doi=10.1210/jc.2008-1410 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19088155  }} </ref>:===
'''Differentials for [[Hypoglycemia]] on the basis of Laboratory findings:'''<ref name="pmid19088155">{{cite journal| author=Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER et al.| title=Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline. | journal=J Clin Endocrinol Metab | year= 2009 | volume= 94 | issue= 3 | pages= 709-28 | pmid=19088155 | doi=10.1210/jc.2008-1410 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19088155  }} </ref>
{|
{| class="sortable"
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! rowspan="2" |Diagnoses
! rowspan="2" |Diagnoses
Line 44: Line 44:
| style="background: #F5F5F5; padding: 5px;text-align: center;" | -
| style="background: #F5F5F5; padding: 5px;text-align: center;" | -
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Insulinoma]]/[[Nesidioblastosis]]/PGPH<sup>†</sup>
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Insulinoma]]
| style="background: #F5F5F5; padding: 5px;text-align: center;" |<55
| rowspan="3" style="background: #F5F5F5; padding: 5px;text-align: center;" |<55
| style="background: #F5F5F5; padding: 5px;text-align: center;" |≥200
| rowspan="3" style="background: #F5F5F5; padding: 5px;text-align: center;" |≥200
| style="background: #F5F5F5; padding: 5px;text-align: center;" |≥3
| rowspan="3" style="background: #F5F5F5; padding: 5px;text-align: center;" |≥3
| style="background: #F5F5F5; padding: 5px;text-align: center;" |≥5
| rowspan="3" style="background: #F5F5F5; padding: 5px;text-align: center;" |≥5
| style="background: #F5F5F5; padding: 5px;text-align: center;" |≤2.7
| rowspan="3" style="background: #F5F5F5; padding: 5px;text-align: center;" |≤2.7
| style="background: #F5F5F5; padding: 5px;text-align: center;" |>25
| rowspan="3" style="background: #F5F5F5; padding: 5px;text-align: center;" |>25
| style="background: #F5F5F5; padding: 5px;text-align: center;" | -
| rowspan="3" style="background: #F5F5F5; padding: 5px;text-align: center;" | -
| style="background: #F5F5F5; padding: 5px;text-align: center;" | -
| rowspan="3" style="background: #F5F5F5; padding: 5px;text-align: center;" | -
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Nesidioblastosis]]
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Post gastric bypass hypoglycemia (PGPH)
|-
|-
| style="background: #DCDCDC; padding: 5px; text-align: center;" |Insulin autoimmune hypoglycemia  
| style="background: #DCDCDC; padding: 5px;text-align: center;" |Insulin autoimmune hypoglycemia  
| style="background: #F5F5F5; padding: 5px;text-align: center;" |<55
| style="background: #F5F5F5; padding: 5px;text-align: center;" |<55
| style="background: #F5F5F5; padding: 5px;text-align: center;" |>>200<sup>‡</sup>
| style="background: #F5F5F5; padding: 5px;text-align: center;" |>>200<sup>‡</sup>
Line 83: Line 87:
| style="background: #F5F5F5; padding: 5px;text-align: center;" | -
| style="background: #F5F5F5; padding: 5px;text-align: center;" | -
| style="background: #F5F5F5; padding: 5px;text-align: center;" | -
| style="background: #F5F5F5; padding: 5px;text-align: center;" | -
|-
| colspan="9" style="background: #DCDCDC; padding: 5px; " |
‡ Free C-peptide and proinsulin concentrations are low<br>
¤ [[IGF]]= Insulin Growth Factor, Increased pro-IGF-2, free [[Insulin-like growth factor 2|IGF]]-2, IGF-2/[[IGF-1]] ratio
|}
|}


† PGPH= Post Gastric Bypass Hypoglycemia,<br>‡ Free C-peptide and proinsulin concentrations are low<br>
'''Differentiating hypoglycemia from other diseases that cause autonomic hyperactivity symptoms :'''
¤ [[IGF]]= Insulin Growth Factor, Increased pro-IGF-2, free [[Insulin-like growth factor 2|IGF]]-2, IGF-2/[[IGF-1]] ratio
{|
 
====Differentiating hypoglycemia from other diseases that cause autonomic hyperactivity symptoms ([[tachycardia]], [[hypertension]]):====
{| class="wikitable sortable"
|+
|+
! rowspan="3" style="background: #4479BA; color: #FFFFFF; " |Disease
! rowspan="3" style="background: #4479BA; color: #FFFFFF; " |Disease
Line 95: Line 101:
! rowspan="3" style="background: #4479BA; color: #FFFFFF; " |Investigations
! rowspan="3" style="background: #4479BA; color: #FFFFFF; " |Investigations
|-
|-
! colspan="4" |Symptoms
! colspan="4" style="background: #4479BA; color: #FFFFFF; " |Symptoms
! rowspan="2" |Signs
! rowspan="2" style="background: #4479BA; color: #FFFFFF; " |Signs
|-
|-
!Tachycardia
! style="background: #4479BA; color: #FFFFFF; " |Palpitations
!Fever
! style="background: #4479BA; color: #FFFFFF; " |Fever
!Sweating
! style="background: #4479BA; color: #FFFFFF; " |Sweating
!Headache
! style="background: #4479BA; color: #FFFFFF; " |Headache
|-
|-
![[Anxiety disorders]]
! style="background: #DCDCDC; text-align: center;" |[[Hypoglycemia]]
|<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" | +
|<nowiki>-</nowiki>
| style="background: #F5F5F5; text-align: center;" | -
|<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" | +
|<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" | +
|
| style="background: #F5F5F5; " |
* [[Tachycardia]]
* Blurred vision
* [[Pallor]]
* [[Tremor|Tremors]]
* [[Seizures]]/ [[Coma]]
| style="background: #F5F5F5; " |
* Plasma [[glucose]] <70 mg/dL
* S. [[Insulin]]
* S. [[Proinsulin]]
* S. [[C-peptide|C-Peptide]]
|-
! style="background: #DCDCDC; text-align: center;" |[[Anxiety disorders]]
| style="background: #F5F5F5; text-align: center;" |<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>-</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>+</nowiki>
| style="background: #F5F5F5;" |
*Patient looks irritable
*Patient looks irritable
*Rapid [[pulse]] and may be irregular
*Rapid [[pulse]] and may be irregular
|
| style="background: #F5F5F5;" |
*Normal investigations
*Normal investigations
|-
|-
![[Pheochromocytoma]]
! style="background: #DCDCDC; text-align: center;" |[[Pheochromocytoma]]
|<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>+</nowiki>
|<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>+</nowiki>
|<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>+</nowiki>
|<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>+</nowiki>
|
| style="background: #F5F5F5;" |
*[[Tachycardia]]
*[[Tachycardia]]
*Strong rapid [[pulse]]
*Strong rapid [[pulse]]
*High [[pulse pressure]]
*High [[pulse pressure]]
|
| style="background: #F5F5F5;" |
*Plasma fractionated [[Metanephrine|metanephrines]], 24-hour urinary fractionated [[Metanephrine|metanephrines]], [[catecholamines]].<ref name="pmid11903030">{{cite journal| author=Lenders JW, Pacak K, Walther MM, Linehan WM, Mannelli M, Friberg P et al.| title=Biochemical diagnosis of pheochromocytoma: which test is best? | journal=JAMA | year= 2002 | volume= 287 | issue= 11 | pages= 1427-34 | pmid=11903030 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11903030  }}</ref>
*Plasma fractionated [[Metanephrine|metanephrines]], 24-hour urinary fractionated [[Metanephrine|metanephrines]], [[catecholamines]].<ref name="pmid11903030">{{cite journal| author=Lenders JW, Pacak K, Walther MM, Linehan WM, Mannelli M, Friberg P et al.| title=Biochemical diagnosis of pheochromocytoma: which test is best? | journal=JAMA | year= 2002 | volume= 287 | issue= 11 | pages= 1427-34 | pmid=11903030 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11903030  }}</ref>
*[[Computed tomography]]: Radiological evaluation should follow lab tests to locate site of  the tumour.<ref name="pmid1787652">{{cite journal| author=Bravo EL| title=Pheochromocytoma: new concepts and future trends. | journal=Kidney Int | year= 1991 | volume= 40 | issue= 3 | pages= 544-56 | pmid=1787652 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1787652  }}</ref>
*[[Computed tomography]]: Radiological evaluation should follow lab tests to locate site of  the tumour.<ref name="pmid1787652">{{cite journal| author=Bravo EL| title=Pheochromocytoma: new concepts and future trends. | journal=Kidney Int | year= 1991 | volume= 40 | issue= 3 | pages= 544-56 | pmid=1787652 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1787652  }}</ref>
|-
|-
![[Arrhythmias|Arrhythmia]]
! style="background: #DCDCDC; text-align: center;" |[[Arrhythmias|Arrhythmia]]
| +
| style="background: #F5F5F5; text-align: center;" | +
|<nowiki>-</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>-</nowiki>
|<nowiki>-</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>-</nowiki>
|
| style="background: #F5F5F5;" |
*Irregular pulse
*Irregular pulse
|
| style="background: #F5F5F5;" |
*ECG changes according to the cause
*ECG changes according to the cause
|-
|-
![[Hyperthyroidism]]
! style="background: #DCDCDC; text-align: center;" |[[Hyperthyroidism]]
| +
| style="background: #F5F5F5; text-align: center;" | +
|<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>+</nowiki>
|<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>+</nowiki>
|<nowiki>+</nowiki>
| style="background: #F5F5F5; text-align: center;" |<nowiki>+</nowiki>
|
| style="background: #F5F5F5;" |
*Hyperactive [[Deep tendon reflex|deep tendon reflexes]]
*Hyperactive [[Deep tendon reflex|deep tendon reflexes]]
*[[Thyromegaly]]
*[[Thyromegaly]]
*[[Exophthalmus]]
*[[Exophthalmus]]
|
| style="background: #F5F5F5;" |
*Level of [[thyroid-stimulating hormone]] ([[TSH]])
*Level of [[thyroid-stimulating hormone]] ([[TSH]])
*Levels of T4 and/or T3 in the blood
*Levels of T4 and/or T3 in the blood
Line 160: Line 180:
{{WH}}
{{WH}}
{{WS}}
{{WS}}
[[Category:Up-To-Date]]
[[Category:Oncology]]
[[Category:Medicine]]
[[Category:Gastroenterology]]
[[Category:Surgery]]

Latest revision as of 21:26, 8 February 2019

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

Overview

Insulinoma must be differentiated from other diseases that cause features of hypoglycemia like altered mental status/confusion, profuse sweating and visual disturbances (blurring/diplopia). These are classified on the basis of laboratory findings into exogenous insulin, oral hypoglycemic agents (e.g. Sulphonylureas), Nesidioblastosis, insulin autoimmune hypoglycemia.

Differentiating insulinoma from other Diseases

Insulinoma must be differentiated from other diseases that cause features of hypoglycemia. These are classified on the basis of laboratory findings.

Differentials for Hypoglycemia on the basis of Laboratory findings:[1]

Diagnoses Laboratory Findings differentiating among causes of Hypoglycemia
S.Glucose
(mg/dL) 		C Peptide (pmol/L) S.Insulin (μU/mL) S.Proinsulin
(pmol/L) 		S. Beta hydroxybutyrate Glucose increase after glucagon(mg/dL) Oral Hypoglycemic agent Antibodies to Insulin
Normal/Fasting <55 <200 <3 <5 >2.7 <25 - -
Exogenous Insulin <55 <200 >>3 <5 ≤2.7 >25 - -
Insulinoma <55 ≥200 ≥3 ≥5 ≤2.7 >25 - -
Nesidioblastosis
Post gastric bypass hypoglycemia (PGPH)
Insulin autoimmune hypoglycemia <55 >>200‡ >>3 >>5‡ ≤2.7 >25 - +
Oral hypoglycemic agent <55 ≥200 ≥3 ≥5 ≤2.7 >25 + -
IGF¤ <55 <200 <3 <5 ≤2.7 >25 - -

‡ Free C-peptide and proinsulin concentrations are low
¤ IGF= Insulin Growth Factor, Increased pro-IGF-2, free IGF-2, IGF-2/IGF-1 ratio

Differentiating hypoglycemia from other diseases that cause autonomic hyperactivity symptoms :

Disease Clinical Manifestation Investigations
Symptoms Signs
Palpitations Fever Sweating Headache
Hypoglycemia + - + +
Anxiety disorders + - + +
  • Patient looks irritable
  • Rapid pulse and may be irregular
  • Normal investigations
Pheochromocytoma + + + +
Arrhythmia + - - -
  • Irregular pulse
  • ECG changes according to the cause
Hyperthyroidism + + + +

References

  1. ↑ Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER; et al. (2009). "Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline". J Clin Endocrinol Metab. 94 (3): 709–28. doi:10.1210/jc.2008-1410. PMID 19088155.
  2. ↑ Lenders JW, Pacak K, Walther MM, Linehan WM, Mannelli M, Friberg P; et al. (2002). "Biochemical diagnosis of pheochromocytoma: which test is best?". JAMA. 287 (11): 1427–34. PMID 11903030.
  3. ↑ Bravo EL (1991). "Pheochromocytoma: new concepts and future trends". Kidney Int. 40 (3): 544–56. PMID 1787652.

Template:WH Template:WS

Retrieved from "https://www.wikidoc.org/index.php?title=Insulinoma_differential_diagnosis&oldid=1547859"