DISCUSSION
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Transcript of DISCUSSION
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DISCUSSION
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Anatomy
• Pancreas: head, uncinate process, neck, body, tail
• Pancreatic duct (Wirsung): joins the CBD at ampulla of Vater enters 2nd part of duodenum at duodenal papillae
• Accessory duct (Santorini): opens into the duodenum
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Anatomy
• Pancreatic gland: – Lobulated– Digestive hormones
• Islets of Langerhans: – α cells secrete glucagon(increase Glucose in blood)– β cells secrete insulin (decrease Glucose in blood)– δ cells secrete somatostatin and Gastrin
(regulates/stops α and β cells)– PP cells secrete pancreatic polypeptide
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Insulinoma• low frequency, insulinoma (a tumor of pancreatic β-cells) is
the most common type of pancreatic endocrine tumors.• annual incidence of 1 to 4 per million• insulinomas are sporadic, small (90% ≤2 cm), solitary (90%)
and benign (>90%)• At presentation, 50% of patients are over 50 years • Median duration of symptoms of 18 months.• Insulinoma has a female preponderance of 59% and, at
diagnosis a 5% rate of malignancy• About 8% of insulinoma patients are diagnosed with
multiple endocrine neoplasia type 1 (MEN-1)
Insulinoma - An Atypical Presentation: Case Report and Literature ReviewRassauoli, Lai, Sargeant (University of Toronto Medical Journal)
volume 82, number 1, December 2004
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Insulinoma - An Atypical Presentation: Case Report and Literature ReviewRassauoli, Lai, Sargeant (University of Toronto Medical Journal)
volume 82, number 1, December 2004
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INSULINOMA
• endocrine tumor of the pancreas derived from beta cells that ectopically secretes insulin, which results in hypoglycemia.
• 40–50 years. • Small; 90% are < 2 cm• not multiple (90%)• 5–15% are malignant• distributed throughout the head, body, and tail
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NEUROGLYCEMIC SYMPTOMS
• The most common clinical symptoms– confusion, headache, disorientation, visual
difficulties, irrational behavior, or even coma.– sweating, tremor, and palpitations
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Fast up to 72 h with serum glucose, C-peptide, and insulin measurements every 4–8 h
<40 mg/dL
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CRITERIA FOR DIAGNOSIS
• Insulin level >6 µU/mL; blood glucose is <40 mg/dL
• Elevated C-peptide and serum proinsulin level• Insulin/glucose ratio >0.3• Decreased plasma B-hydroxybutyrate level
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EXOGENOUS INSULIN
• (N) Proinsulin levels • ↓ C-peptide levels • (+) Antibodies to insulin • Sulfonylurea
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DIAGNOSTIC TECHNIQUES
• CT scanning • Endoscopic ultrasound • Arteriography with catheterization of small
arterial branches of the celiac system combined with calcium injections
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DIFFERENTIALS
• Reactive hypoglycaemia• Functional hypoglycaemia with Gastrectomy• Adrenal Insufficiency• Hypopituitarism• Hepatic Insufficiency• Manchausen syndrome (insulin self-injections)• Nonislet cell tumor causing hypoglycaemia• Surreptitious administration of insulin or OHAs
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MANAGEMENT
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CONSERVATIVE MANAGEMENT• Intake of small frequent meals that are rich in
carbohydrates• Strenuous exercise should be avoided • Medical treatment
• Diazoxide - nondiuretic benzothiadiazine - stimulate b-cell adrenergic receptors decreasing insulin release - standard dose: 150-450mg daily, often divided into doses every 8 hours - side effects: sodium and water retention, hirsutism
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SURGICAL MANAGEMENT
Surgical resection - treatment of choice
• Enucleation of the insulinoma - performed in patients who have a solitary tumor that is not encroaching on the pancreatic duct
• Distal pancreatectomy - performed en-bloc along with resection of the spleen- makes the operation short and easy- tumors are often present in the tail and body of the pancreas
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SURGICAL MANAGEMENT
• Whipple procedure (pancreaticoduodenectomy) - may be required if the tumor is in close
proximity to major ductal structures
• Warshaw's technique- spleen may be preserved by maintaining the
integrity of the short gastric vessels and the left gastro-epiploic vessels
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SURGICAL MANAGEMENT
Complications:pancreatic fistula persistent hyperinsulinism bile leak and prolonged gastric ileus injury to the spleen
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SURGICAL MANAGEMENT
• New TechniquesCryoablationLaparoscopic pancreatic surgery