Endocrine Abstracts

A 48 years old male presented with an acute episode of dizziness, weakness, diaphoresis, palpitations, and shakiness. Hypoglycaemia was confirmed with a CBG of 1.6 mmol/L. His symptoms resolved on treatment with Hypostop gel and 10% dextrose. He had an otherwise unremarkable physical examination. In view of his history of consumption of a bottle of vodka daily a diagnosis of alcohol induced hypoglycaemia was made on discharge. A year later he was found being agitated and aggressive in a shopping centre requiring restraint by police. This was followed by collapse with a CBG of 0.6 mmol/L. He reported having had similar symptoms, of lesser severity, for approximately 2-yr duration, which continued despite his cutting down drinking to 1 pint beer weekly. Whipple’s triad was positive. Endogenous hyperinsulinemic hypoglycaemia was suspected. Insulin level 55 pmol/L (reference range 12–150),C-peptide level 850 pmol/L (reference range 350–1800), Betahydroxybutyrate<100 umol/L, VBG 2.0 mmol/L; insulin antibodies and sulphonylureas screen were negative. Diazoxide and continuous dextrose infusion were initiated as he had recurrent hypoglycaemic episodes with seizures. Ultrasound showed fatty liver. CT abdomen revealed left adrenal incidentaloma which proved non-functional. MRI pancreas and Octreotide scan were normal. Endoscopic ultrasound suggested 11X13 mm hypo-echoic mass in the pancreatic head which could be an insulinoma or an inflammatory lesion. So as to obtain a more definitive evidence of insulinoma an intra-arterial calcium stimulation test was performed which revealed positive rises in the hepatic vein insulin when gastroduodenal and superior mesenteric arteries (supplying the head of pancreas) were injected. Although a Redo-endoscopic ultrasound with FNA was non-diagnostic; a repeat MRI pancreas revealed a 10 mm lesion in the uncinate process. Enucleation of the tumour with occlusion of small vascular feeding branches was successful. The frozen section sample confirmed well differentiation neuroendocrine tumour. The patient was discharged in good health with safe glucose levels.