HYPOGLYCAEMIA IN THE NON-DIABETIC

The causes and mechanism of hypoglycaemia are listed in Table 15.9.

Insulinomas

These are rare pancreatic islet cell tumours (usually benign) that secrete insulin. They may be part of the multiple endocrine neoplasia syndrome (p. 658).

Table 15.8 A sliding scale insulin regime*

Blood glucose (mmol/L)

Human Actrapid (units/hour)

<4

0.5

4.1-7 1

7.1-11

2

11.1-15

3

15.1–20

5

>20

6

*Add 50 units of Human Actrapid to 49.5 ml of 0.9% sodium chloride in a syringe
driver. Give intravenous insulin as above depending on hourly stix testing.
Fluid guide (assuming normal potassium and sodium) – if blood glucose > 12 mmol/L
give 1 L of 0.9% sodium chloride with 20 mmol KCL over 10 hours; if blood glucose <
12 mmol/L give 1 L of 5% glucose with 20 mmol KCL over 10 hours. Use a separate
cannula for insulin and fluids. Patients in heart failure can be given 500 ml 10%
glucose over 10 hours.

Table 15.9 Causes of hypoglycaemia

Cause

Mechanism of hypoglycaemia

Drug induced: insulin, sulfonylureas, quinine, pentamidine, propranolol, salicylates in overdose

Variety of mechanisms

Islet cell tumour of the pancreas (insulinoma)

Inappropriately high circulating insulin levels

Non-pancreatic tumours, e.g. sarcoma, hepatoma

Secretion of IGF-1

Endocrine causes: Addison’s disease

Impaired counter-regulation to the action of insulin

Fulminant liver failure

Failure of hepatic gluconeogenesis

End-stage kidney disease

Failure of renal cortical gluconeogenesis

Excess alcohol

Enhanced insulin response to carbohydrate

  Inhibition of hepatic gluconeogenesis

After gastric surgery

Rapid gastric emptying, mismatch of food and insulin

Factitious hypoglycaemia

Surreptitious self-administration of insulin or sulphonylureas, often in a non-diabetic

IGF-1, insulin -like growth facẨor. normally mainly produced by the liver, primarily a growth factor in physiological concentrations

Clinical features

The classic presentation is with fasting hypoglycaemia. Hypoglycaemia pro-duces symptoms as a result of neuroglycopenia and stimulation of the sym-pathetic nervous system. These include sweating, palpitations, diplopia and weakness, progressing to confusion, abnormal behaviour, fits and coma.

Investigations

The diagnosis is made by demonstrating hypoglycaemia in association with inappropriate or excessive insulin secretion:

■ Measurement of overnight fasting plasma glucose and insulin levels on three occasions

■ Performing a prolonged 72-hour supervised fast if overnight testing is inconclusive and symptoms persist. Blood is taken at intervals for meas-urement of glucose, insulin and C-peptide.

A plasma insulin concentration of 3 |i/mL or more when the plasma glucose is below 3.0 mmol/L indicates an excess of insulin. C-peptide is co-secreted from the pancreas with insulin and is used to distinguish endogenous hyper-insulinaemia (e.g. as a result of an insulinoma when C-peptide levels are detectable) from exogenous hyperinsulinaemia (e.g. due to factitious insulin administration when C-peptide levels are undetectable).

Further investigations are usually necessary to localize tumours before surgery as they are often very small. These include highly selective angiography, high-resolution CT scanning, scanning with radiolabelled soma-tostatin (some tumours express somatostatin receptors) and endoscopic ultrasound.

Treatment

The treatment of choice is surgical excision of the tumour. Diazoxide, which inhibits insulin release from islet cells, is useful when the tumour is malig-nant, in patients in whom a tumour is very small and cannot be located, or in elderly patients with mild symptoms. Symptoms may also remit using a somatostatin analogue (octreotide or lanreotide).

Ebook Essentials of Kumar and Clark's Clinical Medicine, 5e

1. Ethics and communication

Ethics and communication

2. Infectious diseases

Infectious diseases

3. Gastroenterology and nutrition

Gastroenterology and nutrition

4. Liver, biliary tract and pancreatic disease

Liver, biliary tract and pancreatic disease
LIVER BIOCHEMISTRY AND LIVER FUNCTION TESTS
SYMPTOMS AND SIGNS OF LIVER DISEASE
JAUNDICE
HEPATITIS
NON - ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
CIRRHOSIS
COMPLICATIONS AND EFFECTS OF CIRRHOSIS
LIVER TRANSPLANTATION
TYPES OF CHRONIC LIVER DISEASE AND CIRRHOSIS
PRIMARY SCLEROSING CHOLANGITIS
BUDD - CHIARI SYNDROME
LIVER ABSCESS
LIVER DISEASE IN PREGNANCY
LIVER TUMOURS
GALLSTONES
THE PANCREAS
CARCINOMA OF THE PANCREAS
NEUROENDOCRINE TUMOURS OF THE PANCREAS

5. Haematological disease

Haematological disease
ANAEMIA
Assessment and treatment of suspected neutropenic sepsis
HAEMOLYTIC ANAEMIA
INHERITED HAEMOLYTIC ANAEMIAS
ACQUIRED HAEMOLYTIC ANAEMIA
MYELOPROLIFERATIVE DISORDERS
THE SPLEEN
BLOOD TRANSFUSION
THE WHITE CELL
HAEMOSTASIS AND THROMBOSIS
THROMBOSIS
THERAPEUTICS

6. Malignant disease

Malignant disease
MYELOABLATIVE THERAPY AND HAEMOPOIETIC STEM CELL TRANSPLANTATION
THE LYMPHOMAS
THE PARAPROTEINAEMIAS
PALLIATIVE MEDICINE AND SYMPTOM CONTROL

7. Rheumatology

Rheumatology
COMMON INVESTIGATIONS IN MUSCULOSKELETAL DISEASE
COMMON REGIONAL MUSCULOSKELETAL PROBLEMS
BACK PAIN
OSTEOARTHRITIS
INFLAMMATORY ARTHRITIS
THE SERONEGATIVE SPONDYLOARTHROPATHIES
Clinical features, Investigations
INFECTION OF JOINTS AND BONES
AUTOIMMUNE RHEUMATIC DISEASES
SYSTEMIC INFLAMMATORY VASCULITIS
DISEASES OF BONE
THERAPEUTICS

8. Water, electrolytes and acid–base balance

WATER AND ELECTROLYTE REQUIREMENTS
BODY FLUID COMPARTMENTS
REGULATION OF BODY FLUID HOMEOSTASIS
PLASMA OSMOLALITY AND DISORDERS OF SODIUM REGULATION
DISORDERS OF POTASSIUM REGULATION
DISORDERS OF MAGNESIUM REGULATION
DISORDERS OF ACID - BASE BALANCE
THERAPEUTICS

9. Renal disease

Renal disease
INVESTIGATION OF RENAL DISEASE
GLOMERULAR DISEASES
NEPHROTIC SYNDROME
URINARY TRACT INFECTION
TUBULOINTERSTITIAL NEPHRITIS
HYPERTENSION AND THE KIDNEY
RENAL CALCULI AND NEPHROCALCINOSIS
URINARY TRACT OBSTRUCTION
ACUTE RENAL FAILURE/ACUTE KIDNEY INJURY
CHRONIC KIDNEY DISEASE
RENAL REPLACEMENT THERAPY
CYSTIC RENAL DISEASE
TUMOURS OF THE KIDNEY AND GENITOURINARY TRACT
DISEASES OF THE PROSTATE GLAND
TESTICULAR TUMOUR
URINARY INCONTINENCE

10. Cardiovascular disease

COMMON PRESENTING SYMPTOMS OF HEART DISEASE
INVESTIGATIONS IN CARDIAC DISEASE
CARDIAC ARRHYTHMIAS
HEART FAILURE
ISCHAEMIC HEART DISEASE
RHEUMATIC FEVER
VALVULAR HEART DISEASE
PULMONARY HEART DISEASE
MYOCARDIAL DISEASE
CARDIOMYOPATHY
PERICARDIAL DISEASE
SYSTEMIC HYPERTENSION
ARTERIAL AND VENOUS DISEASE
ELECTRICAL CARDIOVERSION
DRUGS FOR ARRHYTHMIAS
DRUGS FOR HEART FAILURE
DRUGS AFFECTING THE RENIN - ANGIOTENSIN SYSTEM
NITRATES, CALCIUM - CHANNEL BLOCKERS AND POTASSIUM - CHANNEL ACTIVATORS

11. Respiratory disease


Respiratory disease
TUBERCULOSISnd
DIFFUSE DISEASES OF THE LUNG PARENCHYMA
OCCUPATIONAL LUNG DISEASE
CARCINOMA OF THE LUNG
DISEASES OF THE CHEST WALL AND PLEURA
DISORDERS OF THE DIAPHRAGM

12. Intensive care medicine

Intensive care medicine

13. Drug therapy, poisoning, and alcohol misuse

Drug therapy, poisoning, and alcohol misuse

14. Endocrine disease

Endocrine disease
PITUITARY HYPERSECRETION SYNDROMES
THE THYROID AXIS
MALE REPRODUCTION AND SEX
FEMALE REPRODUCTION AND SEX
THE GLUCOCORTICOID AXIS
THE THIRST AXIS
DISORDERS OF CALCIUM METABOLISM
DISORDERS OF PHOSPHATE CONCENTRATION
ENDOCRINOLOGY OF BLOOD PRESSURE CONTROL
DISORDERS OF TEMPERATURE REGULATION
THERAPEUTICS

15. Diabetes mellitus and other disorders of metabolism

DIABETES MELLITUS
DIABETIC METABOLIC EMERGENCIES
COMPLICATIONS OF DIABETES
SPECIAL SITUATIONS
HYPOGLYCAEMIA IN THE NON - DIABETIC
DISORDERS OF LIPID METABOLISM
THE PORPHYRIAS

16. The special senses

THE EAR
THE NOSE AND NASAL CAVITY
THE THROAT
THE EYE

17. Neurology

COMMON NEUROLOGICAL SYMPTOMS
COORDINATION OF MOVEMENT
THE CRANIAL NERVES
COMMON INVESTIGATIONS IN NEUROLOGICAL DISEASE
UNCONSCIOUSNESS AND COMA
STROKE AND CEREBROVASCULAR DISEASE
EPILEPSY AND LOSS OF CONSCIOUSNESS
NERVOUS SYSTEM INFECTION AND INFLAMMATION
HYDROCEPHALUS
HEADACHE, MIGRAINE AND FACIAL PAIN
SPINAL CORD DISEASE
DEGENERATIVE NEURONAL DISEASES
DISEASES OF THE PERIPHERAL NERVES
MUSCLE DISEASES
MYOTONIAS
DELIRIUM
THERAPEUTICS

18. Dermatology

Dermatology



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