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Figure 2. Digital subtraction angiogram showing suspected tumor "blush" (arrow) in the region of the head of the pancreas. Table 1 Some Causes of Symptomatic Fasting Hypoglycemia Hyperinsulinism Insulinoma Exogenous insulin administration Oral hypoglycemic agents Alcohol abuse Uremia Cancer Tumor secretion of hypoglycemic peptides Hepatic infiltration and destruction Cachexia Hepatic failure Drugs Aspirin Propranolol Hormonal deficits Adrenal insufficiency Hypopituitarism The patient then underwent a digital subtraction abdominal arteriogram (figure 2), which showed a vascular blush in the head of the pancreas suggesting, but not diagnostic of, an insulinoma. Because the suspected tumor lay in the head of the pancreas, an area frought with surgical hazards, and because a substantial percentage of insulinomas are multiple, we opted to better define the nature of the insulin-secreting process by passing a catheter through the liver into the portal venous system in retrograde fashion, taking blood samples for insulin determinations along the course of the superior mesenteric vein and splenic vein (figure 3). The results showed a single peak of insulin secretion PORTAL VEIN SUPERIOR PANCREATICO- DUODENAL CI^ VEIN ci SUPERIOR MESENTERIC VEIN Figure 3. Results of insulin assay (numbers represent insulin concentration in uUlml) on blood samples obtained during transhepatic venous catheterization of the major veins into which the pancreatic system drains. There is a distinct ''step-up" in concentration at the point where the superior pancreatico-duodenal vein enters the superior mesenteric, and downstream (that is, toward the portal vein) from that point. These data point to a single source of insulin secretion in the head of the pancreas. in the area where the superior pancreatico-duodenal vein (draining the head of the pancreas) entered the superior mesenteric vein. At laparotomy, the patient had a 2 cm by 2 cm tumor overlying the portal vein in the head of the pancreas. It was excised without complication. She had a mild rebound hyperglycemia with serum glucoses recorded near 300 mg/ dl. This rapidly returned to normal and, on discharge nine days after operation, her overnight fasting serum glucose was 94mg/dl and the accompanying serum insulin, 6 uU/ ml. Surgery of the pancreas is never without pitfalls; and our patient's course illustrates why we urge extreme conservatism in the interpretation of diagnostic studies in order to avoid unnecessary pancreatic surgery. The release of pancreatic digestive enzymes from the cut surface of the gland predisposes to problems in wound healing. A draining pancreatico-cutaneous fistula developed, and, 25 days after leaving the hospital, the patient had spontaneous discharge of large amounts of purulent material from her wound site. She was readmitted, the wound was reopened and loculated fluid released. Bacterial cultures were not diagnostic but she was given antibiotics as a precaution. She spent a further two weeks in hospital, slowly regaining strength and spirits. Wound drainage continued for several more months, but eventually stopped; she returned to work and full family life and has remained symptomatically well for over 14 months. Discussion Table 1 shows the differential diagnosis of fasting hypoglycemia.' To the clinician, low blood glucose coupled with the history of strange behavior should bring to mind the suspicion of hyperinsulinism. The diagnostic steps are few.- As when one suspects hyperfunction of any gland, the procedure is to determine whether the function of that gland can be turned off. In normal patients, glucose levels 564 Vol. 47. No. 12
Object Description
Rating | |
Fixed Title * | NCHH-17: North Carolina Medical Journal [1940-Present] |
Document Title | North Carolina Medical Journal [1940-Present] |
Subject Topical Other | Public Health -- Periodicals.; Physicians -- North Carolina -- Directory.; Societies, Medical -- North Carolina -- Periodicals. |
Description | Includes Transactions of the Society, -1960; 1961- , Transactions issued separately, bound in.; Includes Transactions of the auxiliary to the Medical Society of the State of North Carolina and Proceedings of the North Carolina Public Health Association. Official organ of the Medical Society of the State of North Carolina, 1940-May 1972; of the North Carolina Medical Society, June 1972-. Vols. for 1940-May 1972 published by the Medical Society of the State of North Carolina; June 1972- by the North Carolina Medical Society. |
Contributor | Medical Society of the State of North Carolina. Transactions.; Medical Society of the State of North Carolina.; North Carolina Medical Society.; North Carolina Medical Society. Transactions.; North Carolina Public Health Association. Proceedings. |
Publisher | [Winston-Salem] : North Carolina Medical Society [etc.], 1940- |
Repository | University of North Carolina at Chapel Hill. Health Sciences Library. |
Host | University of North Carolina at Chapel Hill |
Date | 1986 |
Identifier | NCHH-17-047 |
Form General | Periodicals |
Language | English |
Rights | This item is part of the North Carolina History of Health Digital Collection. Some materials in the Collection are protected by U.S. copyright law. This item is presented by the Health Sciences Library of the University of North Carolina at Chapel Hill for research and educational purposes. It may not be republished or distributed without permission of the Health Sciences Library. |
Digital Collection | North Carolina History of Health Digital Collection |
Sponsor | The North Carolina History of Health Digital Collection is an open access publishing initiative of the Health Sciences Library of the University of North Carolina at Chapel Hill. Financial support for the initiative was provided in part by a multi-year NC ECHO (Exploring Cultural Heritage Online) digitization grant, awarded by the State Library of North Carolina, and funded through the Library Services and Technology Act (LSTA). |
Volume Number | 47 |
Health Discipline | Medicine |
Digital Format | JPEG 2000 |
Print / Download PDF Version | http://archives.hsl.unc.edu/nchh/nchh-17/nchh-17-047.pdf |
Document Sort | all; nchh-17 |
Volume Link | http://dc.lib.unc.edu/cdm/search/collection/nchh/field/identi/searchterm/NCHH-17-047 |
Title Link | http://dc.lib.unc.edu/cdm/search/collection/nchh/field/documa/searchterm/NCHH-17 |
Catalog Record link | http://search.lib.unc.edu/search?R=UNCb1306322 |
Revision History | done |
Description
Fixed Title * | Page 564 (images) |
Document Title | North Carolina Medical Journal [1940-Present] |
Subject Topical Other | Public Health -- Periodicals.; Physicians -- North Carolina -- Directory.; Societies, Medical -- North Carolina -- Periodicals. |
Description | Includes Transactions of the Society, -1960; 1961- , Transactions issued separately, bound in.; Includes Transactions of the auxiliary to the Medical Society of the State of North Carolina and Proceedings of the North Carolina Public Health Association. Official organ of the Medical Society of the State of North Carolina, 1940-May 1972; of the North Carolina Medical Society, June 1972-. Vols. for 1940-May 1972 published by the Medical Society of the State of North Carolina; June 1972- by the North Carolina Medical Society. |
Contributor | Medical Society of the State of North Carolina. Transactions.; Medical Society of the State of North Carolina.; North Carolina Medical Society.; North Carolina Medical Society. Transactions.; North Carolina Public Health Association. Proceedings. |
Publisher | [Winston-Salem] : North Carolina Medical Society [etc.], 1940- |
Repository | University of North Carolina at Chapel Hill. Health Sciences Library. |
Host | University of North Carolina at Chapel Hill |
Date | 1986 |
Identifier | NCHH-17-047-0564 |
Form General | Periodicals |
Page Type | all; all images; diagram; all images; chart/table; article; all images; photo |
Language | English |
Rights | This item is part of the North Carolina History of Health Digital Collection. Some materials in the Collection are protected by U.S. copyright law. This item is presented by the Health Sciences Library of the University of North Carolina at Chapel Hill for research and educational purposes. It may not be republished or distributed without permission of the Health Sciences Library. |
Filename | ncmed471986medi2_0564.jp2 |
Digital Collection | North Carolina History of Health Digital Collection |
Sponsor | The North Carolina History of Health Digital Collection is an open access publishing initiative of the Health Sciences Library of the University of North Carolina at Chapel Hill. Financial support for the initiative was provided in part by a multi-year NC ECHO (Exploring Cultural Heritage Online) digitization grant, awarded by the State Library of North Carolina, and funded through the Library Services and Technology Act (LSTA). |
Volume Number | 47 |
Issue Number | 12 |
Page Number | 564 |
Health Discipline | Medicine |
Full Text | Figure 2. Digital subtraction angiogram showing suspected tumor "blush" (arrow) in the region of the head of the pancreas. Table 1 Some Causes of Symptomatic Fasting Hypoglycemia Hyperinsulinism Insulinoma Exogenous insulin administration Oral hypoglycemic agents Alcohol abuse Uremia Cancer Tumor secretion of hypoglycemic peptides Hepatic infiltration and destruction Cachexia Hepatic failure Drugs Aspirin Propranolol Hormonal deficits Adrenal insufficiency Hypopituitarism The patient then underwent a digital subtraction abdominal arteriogram (figure 2), which showed a vascular blush in the head of the pancreas suggesting, but not diagnostic of, an insulinoma. Because the suspected tumor lay in the head of the pancreas, an area frought with surgical hazards, and because a substantial percentage of insulinomas are multiple, we opted to better define the nature of the insulin-secreting process by passing a catheter through the liver into the portal venous system in retrograde fashion, taking blood samples for insulin determinations along the course of the superior mesenteric vein and splenic vein (figure 3). The results showed a single peak of insulin secretion PORTAL VEIN SUPERIOR PANCREATICO- DUODENAL CI^ VEIN ci SUPERIOR MESENTERIC VEIN Figure 3. Results of insulin assay (numbers represent insulin concentration in uUlml) on blood samples obtained during transhepatic venous catheterization of the major veins into which the pancreatic system drains. There is a distinct ''step-up" in concentration at the point where the superior pancreatico-duodenal vein enters the superior mesenteric, and downstream (that is, toward the portal vein) from that point. These data point to a single source of insulin secretion in the head of the pancreas. in the area where the superior pancreatico-duodenal vein (draining the head of the pancreas) entered the superior mesenteric vein. At laparotomy, the patient had a 2 cm by 2 cm tumor overlying the portal vein in the head of the pancreas. It was excised without complication. She had a mild rebound hyperglycemia with serum glucoses recorded near 300 mg/ dl. This rapidly returned to normal and, on discharge nine days after operation, her overnight fasting serum glucose was 94mg/dl and the accompanying serum insulin, 6 uU/ ml. Surgery of the pancreas is never without pitfalls; and our patient's course illustrates why we urge extreme conservatism in the interpretation of diagnostic studies in order to avoid unnecessary pancreatic surgery. The release of pancreatic digestive enzymes from the cut surface of the gland predisposes to problems in wound healing. A draining pancreatico-cutaneous fistula developed, and, 25 days after leaving the hospital, the patient had spontaneous discharge of large amounts of purulent material from her wound site. She was readmitted, the wound was reopened and loculated fluid released. Bacterial cultures were not diagnostic but she was given antibiotics as a precaution. She spent a further two weeks in hospital, slowly regaining strength and spirits. Wound drainage continued for several more months, but eventually stopped; she returned to work and full family life and has remained symptomatically well for over 14 months. Discussion Table 1 shows the differential diagnosis of fasting hypoglycemia.' To the clinician, low blood glucose coupled with the history of strange behavior should bring to mind the suspicion of hyperinsulinism. The diagnostic steps are few.- As when one suspects hyperfunction of any gland, the procedure is to determine whether the function of that gland can be turned off. In normal patients, glucose levels 564 Vol. 47. No. 12 |
Digital Format | JPEG 2000 |
Print / Download PDF Version | http://archives.hsl.unc.edu/nchh/nchh-17/nchh-17-047.pdf |
Document Sort | all; nchh-17 |
Article Title | Getting Up Groggy |
Article Author | Lisa A. Giannetto; Francis A. Neelon |
Volume Link | http://dc.lib.unc.edu/cdm/search/collection/nchh/field/identi/searchterm/NCHH-17-047 |
Title Link | http://dc.lib.unc.edu/cdm/search/collection/nchh/field/documa/searchterm/NCHH-17 |
Catalog Record link | http://search.lib.unc.edu/search?R=UNCb1306322 |
Revision History | done |
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