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Thapa S, Kaur K, Yadav GK, Kumari D, Phulware RH. Non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS)/ Nesidioblastosis as the underlying cause of recurrent hypoglycemia in a diabetic adult. Autops Case Rep 2023; 13:e2023451. [PMID: 38034512 PMCID: PMC10687782 DOI: 10.4322/acr.2023.451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/05/2023] [Indexed: 12/02/2023]
Abstract
Non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS), without previous bariatric surgery, is a rare form of hypoglycemia in adult patients and is associated with nesidioblastosis. Adult-onset nesidioblastosis in diabetic patients is rare and histologically identical to "non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS)". Nesidioblastosis is rare in adults and clinically and biochemically mimics Insulinoma. In the literature, there have only been four cases of adult nesidioblastosis that followed diabetes mellitus. We report a case of nesidioblastosis in a 36-year-old diabetic female presenting with dizziness, sweating, and palpitations for three years. Selective non-invasive techniques failed to detect a tumor. Based on the pursuit of an insulinoma, a distal pancreatectomy specimen was received at our laboratory, and a diagnosis of nesidioblastosis was made. She is currently on follow-up with a favorable outcome. The definitive diagnosis of nesidioblastosis is made on a histological basis. The preferred form of treatment is pancreatic surgical resection. Nesidioblastosis should be taken into consideration in cases where diabetes transforms into hyperinsulinemic hypoglycemia.
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Affiliation(s)
- Samikshya Thapa
- All India Institute of Medical Sciences AIIMS, Department of Pathology & Laboratory Medicine, Rishikesh, Uttarakhand, India
| | - Kirandeep Kaur
- All India Institute of Medical Sciences, Department of Endocrinology, Rishikesh, Uttarakhand, India
| | - Gajendra Kumar Yadav
- All India Institute of Medical Sciences AIIMS, Department of Pathology & Laboratory Medicine, Rishikesh, Uttarakhand, India
| | - Divya Kumari
- All India Institute of Medical Sciences AIIMS, Department of Pathology & Laboratory Medicine, Rishikesh, Uttarakhand, India
| | - Ravi Hari Phulware
- All India Institute of Medical Sciences AIIMS, Department of Pathology & Laboratory Medicine, Rishikesh, Uttarakhand, India
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Nakagawa R, Minamiguchi S, Kataoka TR, Fujikura J, Masui T, Fujimoto M, Yamada Y, Takeuchi Y, Teramoto Y, Ito H, Saka M, Kitamura K, Otsuki S, Nishijima R, Haga H. Circularity of islets is a distinct marker for the pathological diagnosis of adult non-neoplastic hyperinsulinemic hypoglycemia using surgical specimens. Diagn Pathol 2023; 18:115. [PMID: 37864201 PMCID: PMC10588153 DOI: 10.1186/s13000-023-01403-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/17/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Adult non-neoplastic hyperinsulinemic hypoglycemia (ANHH), also known as adult-onset nesidioblastosis, is a rare cause of endogenous hyperinsulinemic hypoglycemia in adults. This disease is characterized by diffuse hyperplasia of pancreatic endocrine cells and is diagnosed by a pathological examination. While diagnostic criteria for this disease have already been proposed, we established more quantitative criteria for evaluating islet morphology. METHODS We measured the number, maximum diameter, total area, and circularity (representing how closely islets resemble perfect spheres) of islets contained in representative sections of ANHH (n = 4) and control cases (n = 5) using the NIS-Elements software program. We also measured the average cell size, percentage of cells with enlarged nuclei, and percentage of cells with recognizable nucleoli for each of three representative islets. We also assessed the interobserver diagnostic concordance of ANHH between five experienced and seven less-experienced pathologists. RESULTS There was no significant difference in the number, maximum diameter, or total area of islets between the two groups, even after correcting for these parameters per unit area. However, the number of islets with low circularity (< 0.71) per total area of the pancreatic parenchyma was significantly larger in ANHH specimens than in controls. We also found that the percentage of cells with recognizable nucleoli was significantly higher in the ANHH group than in the controls. There were no significant differences in the average cell size or the number of cells with enlarged nuclei between the groups. The correct diagnosis rate with the blind test was 47.5% ± 6.12% for experienced pathologists and 50.0% ± 8.63% for less-experienced pathologists, with no significant differences noted. CONCLUSIONS Low circularity, which indicates an irregular islet shape, referred to as "irregular shape and occasional enlargement of islets" and "lobulated islet structure" in a previous report, is a useful marker for diagnosing ANHH. An increased percentage of recognizable nucleoli, corresponding to "macronucleoli in β-cells," has potential diagnostic value.
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Affiliation(s)
- Ryota Nakagawa
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
- Department of Pathology, Iwate Medical University, Yahaba-cho, Shiwa-gun, Iwate, 028-3694, Japan
| | - Sachiko Minamiguchi
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Tatsuki R Kataoka
- Department of Pathology, Iwate Medical University, Yahaba-cho, Shiwa-gun, Iwate, 028-3694, Japan
| | - Junji Fujikura
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Toshihiko Masui
- Department of Department of Hepatobiliary Pancreatic Surgery and Transplantation, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Masakazu Fujimoto
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yosuke Yamada
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yasuhide Takeuchi
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yuki Teramoto
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hiroaki Ito
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Manduwa Saka
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kyohei Kitamura
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shinya Otsuki
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Ryohei Nishijima
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hironori Haga
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, 606-8507, Japan
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Al-Ameer A, Alsomali A, Habib Z. Incidence, predictors and outcomes of redo pancreatectomy in infants with congenital hyperinsulinism: a 16-year tertiary center experience. Pediatr Surg Int 2023; 39:183. [PMID: 37079145 DOI: 10.1007/s00383-023-05470-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2023] [Indexed: 04/21/2023]
Abstract
PURPOSE Recurrent severe hypoglycemic attacks often persist even after performing pancreatectomy for medically unresponsive congenital hyperinsulinism (CHI). In this study, we present our experience with redo pancreatectomy for CHI. METHODS We reviewed all children who underwent pancreatectomy for CHI between January 2005 and April 2021 in our center. A comparison was made between patients whose hypoglycemia was controlled after primary pancreatectomy and patients who required reoperation. RESULTS A total of 58 patients underwent pancreatectomy for CHI. Refractory hypoglycemia after pancreatectomy occurred in 10 patients (17%), who subsequently underwent redo pancreatectomy. All patients who required redo pancreatectomy had positive family history of CHI (p = 0.0031). Median extent of initial pancreatectomy was lesser in the redo group with borderline level of statistical significance (95% vs. 98%, p = 0.0561). Aggressive pancreatectomy at the initial surgery significantly (p = 0.0279) decreased the risk for the need to redo pancreatectomy; OR 0.793 (95% CI 0.645-0.975). Incidence of diabetes was significantly higher in the redo group (40% vs. 9%, p = 0.033). CONCLUSION Pancreatectomy with 98% extent of resection for diffuse CHI, especially with positive family history of CHI, is warranted to decrease the chance of reoperation for persistent severe hypoglycemia.
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Affiliation(s)
- Ali Al-Ameer
- Department of Pediatric Surgery, King Fahad Medical City, PO Box 59046, Riyadh, 11525, Kingdom of Saudi Arabia.
| | - Afrah Alsomali
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, 11211, Kingdom of Saudi Arabia
| | - Zakaria Habib
- Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, 11211, Kingdom of Saudi Arabia
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4
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Terryn FX, Majerus B. Combined laparoscopic Roux-en-Y gastric bypass reversal and gastric banding to treat severe hyperinsulinemic hypoglycemia: A case report and surgical video. Int J Surg Case Rep 2022; 96:107271. [PMID: 35716625 PMCID: PMC9213248 DOI: 10.1016/j.ijscr.2022.107271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/29/2022] [Accepted: 05/29/2022] [Indexed: 02/07/2023] Open
Abstract
Non insulinoma pancreatogenous hypoglycemia syndrome is a recently described complication of Roux-en-Y gastric bypass Currently, there is no Gold Standard treatment. In this case, we successfully performed a combined laparoscopic reversal of gastric bypass and gastric banding
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Affiliation(s)
- F.-X. Terryn
- Europe Hospitals – Sainte Elisabeth, Brussels, Belgium,Corresponding author.
| | - B. Majerus
- Clinique Saint Pierre, Ottignies, Belgium
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Castillo-López MG, Fernandez MF, Sforza N, Barbás NC, Pattin F, Mendez G, Ogresta F, Gondolesi I, Barros Schelotto P, Musso C, Gondolesi GE. Hyperinsulinemic hypoglycemia in adolescents: case report and systematic review. Clin Diabetes Endocrinol 2022; 8:3. [PMID: 35296370 PMCID: PMC8925193 DOI: 10.1186/s40842-022-00138-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 02/14/2022] [Indexed: 11/26/2022] Open
Abstract
Background Hyperinsulinemic hypoglycemia is the most common cause of severe and persistent hypoglycemia in neonates and children. It is a heterogeneous condition with dysregulated insulin secretion, which persists in the presence of low blood glucose levels. Case presentation We report a case of a 15 year-old male with hyperinsulinemic hypoglycemia, who underwent a subtotal pancreatectomy after inadequate response to medical therapy. Pathological examination was positive for nesidioblastosis (diffuse β-cell hyperplasia by H-E and immunohistochemical techniques). The patient’s blood glucose levels normalized after surgery and he remains asymptomatic after 1 year of follow-up. The systematic review allowed us to identify 41 adolescents from a total of 205 cases reported in 22 manuscripts, from a total of 454 found in the original search done in PubMed and Lilacs. Conclusions Although very well reported in children, hyperinsulinemic hypoglycemia can occur in adolescents or young adults, as it happens in our reported case. These patients can be seen, treated and reported by pediatricians or adult teams either way due to the wide age range used to define adolescence. Most of them do not respond to medical treatment, and subtotal distal pancreatectomy has become the elected procedure with excellent long-term response in the vast majority.
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Affiliation(s)
- M G Castillo-López
- Diabetes Metabolic department, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - M F Fernandez
- General Surgery, Liver, Intestinal and Pancreas Transplant Services, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - N Sforza
- Diabetes Metabolic department, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - N C Barbás
- Anatomo pathology department, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - F Pattin
- General Surgery, Liver, Intestinal and Pancreas Transplant Services, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - G Mendez
- Oncology department Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - F Ogresta
- Imaxe Radiology Institute, Buenos Aires, Argentina
| | - I Gondolesi
- Medical Student, Facultad de Medicina, Universidad Favaloro, Buenos Aires, Argentina
| | - P Barros Schelotto
- General Surgery, Liver, Intestinal and Pancreas Transplant Services, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - C Musso
- Diabetes Metabolic department, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - G E Gondolesi
- General Surgery, Liver, Intestinal and Pancreas Transplant Services, Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina. .,General Surgery Department, and Liver, Pancreas and Intestinal Transplant Units., University Hospital, Favaloro Foundation, Avenida Belgrano 1782, 7mo piso (1093), Buenos Aires, Argentina.
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Torres-Arano SE, Fernández-Baez N, Torres-González MG, González-Cabrera IG, López-Rosales F. Hyperinsulinemic hypoglycemia in adults. Nesidioblastosis case report and review of the literature. CIR CIR 2021; 89:70-75. [PMID: 34762634 DOI: 10.24875/ciru.20001253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hypoglycemia due to endogenous hyperinsulinism usually occurs in 2 pathological situations: the most frequent is insulinoma and, secondly, nesidioblastosis or also known as non-insulinoma pancreatic hypoglycemic syndrome. Nesidioblastosis is a rare cause of hyperinsulinic hypoglycemia in adults. We present the clinical case of an adult patient with recurrent hypoglycemia secondary to nesidioblastosis.
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Affiliation(s)
- Saúl E Torres-Arano
- Servicio de Cirugía General, Hospital Regional de Alta Especialidad de la Península de Yucatán, Mérida, Yucatán
| | | | - Manuel G Torres-González
- Servicio de Cirugía General, Hospital Regional de Alta Especialidad de la Península de Yucatán, Mérida, Yucatán
| | - Itzel G González-Cabrera
- Departamento de Investigación, Hospital Regional de Alta Especialidad de la Península de Yucatán, Mérida, Yucatán. México
| | - Federico López-Rosales
- Servicio de Cirugía General, Hospital Regional de Alta Especialidad de la Península de Yucatán, Mérida, Yucatán
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Shono T, Shono K, Hashimoto Y, Taguchi S, Masuda M, Muramori K, Taguchi T. Congenital hyperinsulinism associated with Hirschsprung's disease-a report of an extremely rare case. Surg Case Rep 2020; 6:4. [PMID: 31916119 PMCID: PMC6949352 DOI: 10.1186/s40792-020-0778-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 12/31/2019] [Indexed: 11/21/2022] Open
Abstract
Background Congenital hyperinsulinism (CH) is a rare disease, characterized by severe hypoglycemia induced by inappropriate insulin secretion from pancreatic beta-cells in neonate and infant. Hirschsprung’s disease (HD) is also a rare disease in which infants show severe bowel movement disorder. We herein report an extremely rare case of combined CH and HD. Case presentation The patient was a full-term male infant who showed poor feeding, vomiting, and hypotonia with lethargy on the day of birth. He was transferred to tertiary hospital after a laboratory analysis revealed hyperinsulinemic hypoglycemia. The patient showed remarkable abdominal distension without meconium defecation. An abdominal X-ray showed marked dilatation of the large bowel. He was diagnosed with CH (nesidioblastosis) associated with suspected HD. He was initially treated with an intravenous infusion of high-dose glucose with the intermittent injection of glucagon. This was successfully followed by treatment with diazoxide and octreotide (a somatostatin analog). At 8 months of age, HD was confirmed by the acetylcholinesterase staining of a rectal mucosal biopsy specimen, and a transanal pull-through operation was performed to treat HD. At 14 months of age, subtotal pancreatectomy was performed for the treatment of focal CH located in the pancreatic body. His postoperative course over the past 12 years has been uneventful without any neurologic or bowel movement disorders. Conclusions Although it is extremely rare for CH to be associated with HD, associated HD should be considered when a patient with CH presents severe constipation.
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Affiliation(s)
- Takeshi Shono
- Department of Pediatric Surgery, National Hospital Organization, Kokura Medical Center, Harugaoka 10-1, Kokuraminami-Ku, Kitakyushu, 803-8533, Japan.
| | - Kumiko Shono
- Department of Pediatric Surgery, National Hospital Organization, Kokura Medical Center, Harugaoka 10-1, Kokuraminami-Ku, Kitakyushu, 803-8533, Japan
| | - Yoshiko Hashimoto
- Department of Pediatric Surgery, National Hospital Organization, Kokura Medical Center, Harugaoka 10-1, Kokuraminami-Ku, Kitakyushu, 803-8533, Japan
| | - Shohei Taguchi
- Department of Pediatric Surgery, Kitakyushu Medical Center, Kitakyushu, Japan
| | - Masanori Masuda
- Department of Pathology, Saga-ken Medical Center Koseikan, Saga, Japan
| | - Kastumi Muramori
- Department of Pediatric Surgery, Saga-ken Medical Center Koseikan, Saga, Japan
| | - Tomoaki Taguchi
- Department of Pediatric Surgery, Kyushu University, Fukuoka, Japan
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Awramiszyn-Fernández N, Paz-Ibarra JL, Suárez-Rojas J, Rodríguez-Alegría CE, Somocurcio-Peralta JR, Ramírez-Delpino EJ, Teruya-Gibu AA. Hyperinsulinemic hypoglycemia caused by nesidioblastosis associated with non-surgical weight loss. Rev Med Inst Mex Seguro Soc 2020; 58:528-535. [PMID: 34543561 DOI: 10.24875/rmimss.m20000080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCCIÓN La nesidioblastosis es una enfermedad poco frecuente en los adultos caracterizada por hiperplasia de los islotes pancreáticos, produciendo hipoglucemia por incremento de la producción de insulina. Su patogenia es poco conocida. Clínicamente se ha descrito un cuadro de hipoglucemia con valores elevados de insulina y de péptido C sin ninguna lesión tumoral pancreática detectable. El diagnóstico final es histopatológico. CASO CLÍNICO Mujer de 36 años que cursa con episodios recurrentes de hipoglucemia sintomática de predominio posprandial, asociada a elevación de los valores sanguíneos de insulina y péptido C. Los estudios de imágenes (tomografía computarizada trifásica, resonancia magnética, ecoendoscopia y octreoscan) no mostraron lesiones compatibles con insulinoma. Se le realizó estimulación intraarterial con calcio, que mostró un incremento de la insulinemia en más de un segmento pancreático posestimulación. La paciente fue sometida a pancreatectomía corporocaudal, cuya evaluación histopatológica informó de nesidioblastosis. CONCLUSIONES La nesidioblastosis representa menos del 5% de los casos de hipoglucemia hiperinsulinémica en los adultos, por lo que debe considerarse como diagnóstico -diferencial en estos pacientes; su diagnóstico es difícil y requiere confirmación histopatológica. BACKGROUND Nesidioblastosis is a rare disease in adults caused by pancreatic islet hyperplasia, producing hypoglycemia due to an increase in insulin production. The pathogenesis is poorly understood, however a clinical picture characterized by hypoglycemia with high levels of insulin and C-peptide without any detectable pancreatic lesion has been described, its final diagnosis is histological. CASE REPORT We report a case of a 36-year-old female patient who presents with recurrent episodes of hypoglycemia symptomatic predominantly postprandial, associated with insulin and C-peptide elevation. Images were made (triphasic computed tomography, magnetic resonance imaging, echoendoscopy and octreoscan), being negative for insulinoma. Subsequent tests included calcium stimulation of the pancreas, revealing marked insulin release in more than one pancreatic segment. The patient was subjected to distal pancreatectomy confirming in the histological study the diagnosis of nesidioblastosis. CONCLUSIONS Nesidioblastosis accounts for less than 5% of the cases of cases of hyperinsulinemic hypoglycemia in adult patients, should be considered as a differential diagnosis in patients with persistent hypoglycemia, the diagnosis is difficult and usually requires histological confirmation.
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Affiliation(s)
- Natalia Awramiszyn-Fernández
- Hospital Nacional Edgardo Rebagliati Martins, Departamento de Enfermedades Sistémicas, Servicio de Endocrinología
| | - José Luis Paz-Ibarra
- Hospital Nacional Edgardo Rebagliati Martins, Departamento de Enfermedades Sistémicas, Servicio de Endocrinología
| | - Jacsel Suárez-Rojas
- Hospital Nacional Edgardo Rebagliati Martins, Departamento de Enfermedades Sistémicas, Servicio de Endocrinología
| | | | - José René Somocurcio-Peralta
- Hospital Nacional Edgardo Rebagliati Martins, Departamento de Anatomía Patológica, Servicio de Patología Quirúrgica
| | - Enrique Javier Ramírez-Delpino
- Hospital Nacional Edgardo Rebagliati Martins, Departamento de Imagenología, Servicio de Radiología Intervencionista. Lima, Perú
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Canbaz F, Aydın M, Can Meydan B, Ceyhan Bilgici M, Arıtürk E. Striking Visualization of Diffuse Congenital Nesidioblastosis on Ga-68 DOTATATE PET/CT. Mol Imaging Radionucl Ther 2019; 28:83-85. [PMID: 31237140 PMCID: PMC6592318 DOI: 10.4274/mirt.galenos.2018.38039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
“Nesidioblastosis”, later renamed as “persistent hyperinsulinemic hypoglycemia of infancy” presents as either focal or diffuse neo-differentiation of pancreatic Langerhans islet cells from the ductal epithelium. Differentiation of focal disease from diffuse involvement is crucial for optimal disease management. The current methods used to differentiate the two forms pre-operatively are invasive techniques. The definite role of imaging modalities to differentiate diffuse versus focal form has not yet been proven. Herein, we report a 15 day-old infant having diffuse nesidioblastosis, successfully demonstrated by Ga-68 DOTATATE positron emission tomography/computed tomography imaging that was histopathologically confirmed.
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Affiliation(s)
- Fevziye Canbaz
- Ondokuz Mayıs University Hospital, Department of Nuclear Medicine, Samsun, Turkey
| | - Murat Aydın
- Ondokuz Mayıs University Hospital, Department of Pediatric Endocrinology, Samsun, Turkey
| | - Bilge Can Meydan
- Ondokuz Mayıs University Hospital, Department of Pathology, Samsun, Turkey
| | - Meltem Ceyhan Bilgici
- Ondokuz Mayıs University Hospital, Department of Pediatric Radiology, Samsun, Turkey
| | - Ender Arıtürk
- Ondokuz Mayıs University Hospital, Department of Pediatric Surgery, Samsun, Turkey
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Abstract
Postprandial symptoms of neuroglycopenia after bariatric surgery may result as a consequence of endogenous hyperinsulinemic hypoglycemia (nesidioblastosis) not dumping syndrome. Pancreatectomy is an acceptable treatment for this condition. We present the video of a case of near-total distal robotic pancreactectomy for the treatment of nesidioblastosis after Roux-en-Y gastric bypass. Robotic pancreatectomy is an alternative to the treatment of nesidioblastosis after Roux-en-Y gastric bypass.
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Affiliation(s)
| | - Jairo Tabacow Hidal
- Hospital Israelita Albert Einstein, Av. Albert Einstein, 627 - 5° Andar - Salas 512 e 514, Sao Paulo, 05652-900, Brazil
| | - Wagner Marcondes
- Hospital Israelita Albert Einstein, Av. Albert Einstein, 627 - 5° Andar - Salas 512 e 514, Sao Paulo, 05652-900, Brazil
| | - Fernando Concilio Mauro
- Hospital Israelita Albert Einstein, Av. Albert Einstein, 627 - 5° Andar - Salas 512 e 514, Sao Paulo, 05652-900, Brazil
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11
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Yousuf MS, Butt MN, Khan FA. Anaesthetic Management Of Nesidioblastosis In Two Infants. J Ayub Med Coll Abbottabad 2017; 29:689-691. [PMID: 29331007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Nesidioblastosis is the most common cause of non-transient, recurrent and persistent hypoglycaemia in neonates and infants. It is a disorder of diffuse proliferation of beta cells of the pancreas leading to hyperinsulinemia and hypoglycaemia. The main aim is to prevent the severe episodes of hypoglycaemia which can cause damage to the brain and/or mental retardation. In this case report we present two cases of nesidioblastosis and their perioperative anaesthetic course for near-total pancreatectomy. First case was a 7 months old female who had repeated episodes of convulsions since birth. Second case was a 4-month-old female child who again presented with seizures. The challenges faced in the perioperative period were the management of perioperative blood glucose levels and haemodynamic stability.
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Affiliation(s)
| | - Mohsin Nazir Butt
- Department of Anaesthesiology, Aga Khan University Hospital Karachi, Pakistan
| | - Fauzia Anis Khan
- Department of Anaesthesiology, Aga Khan University Hospital Karachi, Pakistan
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Mori F, Sarti L, Barni S, Lodi L, Federico G, Novembre E. Unsuccessful Desensitization in a Child with Hypersensitivity to Diazoxide. Iran J Allergy Asthma Immunol 2017; 16:457-459. [PMID: 29149786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Accepted: 10/28/2017] [Indexed: 06/07/2023]
Abstract
No Abstract.
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Affiliation(s)
- Francesca Mori
- Allergy Unit, Department of Pediatrics, Anna Meyer Children's University Hospital, Florence, Italy
| | - Lucrezia Sarti
- Allergy Unit, Department of Pediatrics, Anna Meyer Children's University Hospital, Florence, Italy
| | - Simona Barni
- Allergy Unit, Department of Pediatrics, Anna Meyer Children's University Hospital, Florence, Italy
| | - Lorenzo Lodi
- Allergy Unit, Department of Pediatrics, Anna Meyer Children's University Hospital, Florence, Italy
| | - Giovanni Federico
- Unit of Pediatric Endocrinology and Diabetes, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Elio Novembre
- Allergy Unit, Department of Pediatrics, Anna Meyer Children's University Hospital, Florence, Italy
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Abstract
AIMS/HYPOTHESIS Post-bariatric hypoglycaemia (PBH) is a rare, but severe, metabolic disorder arising months to years after bariatric surgery. It is characterised by symptomatic postprandial hypoglycaemia, with inappropriately elevated insulin concentrations. The relative contribution of exaggerated incretin hormone signalling to dysregulated insulin secretion and symptomatic hypoglycaemia is a subject of ongoing inquiry. This study was designed to test the hypothesis that PBH and associated symptoms are primarily mediated by glucagon-like peptide-1 (GLP-1). METHODS We conducted a double-blinded crossover study wherein eight participants with confirmed PBH were assigned in random order to intravenous infusion of the GLP-1 receptor (GLP-1r) antagonist. Exendin (9-39) (Ex-9), or placebo during an OGTT on two separate days at the Stanford University Clinical and Translational Research Unit. Metabolic, symptomatic and pharmacokinetic variables were evaluated. Results were compared with a cohort of BMI- and glucose-matched non-surgical controls (NSCs). RESULTS Infusion of Ex-9 decreased the time to peak glucose and rate of glucose decline during OGTT, and raised the postprandial nadir by over 70%, normalising it relative to NSCs and preventing hypoglycaemia in all PBH participants. Insulin AUC and secretion rate decreased by 57% and 71% respectively, and peak postprandial insulin was normalised relative to NSCs. Autonomic and neuroglycopenic symptoms were significantly reduced during Ex-9 infusion. CONCLUSIONS/INTERPRETATION GLP-1r blockade prevented hypoglycaemia in 100% of individuals, normalised beta cell function and reversed neuroglycopenic symptoms, supporting the conclusion that GLP-1 plays a primary role in mediating hyperinsulinaemic hypoglycaemia in PBH. Competitive antagonism at the GLP-1r merits consideration as a therapeutic strategy. TRIAL REGISTRATION ClinicalTrials.gov NCT02550145.
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Affiliation(s)
- Colleen M Craig
- Department of Medicine, Division of Endocrinology, Stanford University School of Medicine, 300 Pasteur Drive, Room S025, Stanford, CA, 94305, USA.
| | - Li-Fen Liu
- Department of Medicine, Division of Endocrinology, Stanford University School of Medicine, 300 Pasteur Drive, Room S025, Stanford, CA, 94305, USA
| | - Carolyn F Deacon
- Department of Biomedical Sciences, Panum Institute, University of Copenhagen, Copenhagen, Denmark
| | - Jens J Holst
- Department of Biomedical Sciences, Panum Institute, University of Copenhagen, Copenhagen, Denmark
| | - Tracey L McLaughlin
- Department of Medicine, Division of Endocrinology, Stanford University School of Medicine, 300 Pasteur Drive, Room S025, Stanford, CA, 94305, USA
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Davi MV, Pia A, Guarnotta V, Pizza G, Colao A, Faggiano A. The treatment of hyperinsulinemic hypoglycaemia in adults: an update. J Endocrinol Invest 2017; 40:9-20. [PMID: 27624297 DOI: 10.1007/s40618-016-0536-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 08/17/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Treatment of hyperinsulinemic hypoglycaemia (HH) is challenging due to the rarity of this condition and the difficulty of differential diagnosis. The aim of this article is to give an overview of the recent literature on the management of adult HH. METHODS A search for reviews, original articles, original case reports between 1995 and 2016 in PubMed using the following keywords: hyperinsulinemic hypoglycaemia, insulinoma, nesidioblastosis, gastric bypass, autoimmune hypoglycaemia, hyperinsulinism, treatment was performed. RESULTS One hundred and forty articles were selected and analysed focusing on the most recent treatments of HH. CONCLUSIONS New approaches to treatment of HH are available including mini-invasive surgical techniques and alternative local-regional ablative therapy for benign insulinoma and everolimus for malignant insulinoma. A correct differential diagnosis is of paramount importance to avoid unnecessary surgical operations and to implement the appropriate treatment mainly in the uncommon forms of HH, such as nesidioblastosis and autoimmune hypoglycaemia.
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Affiliation(s)
- M V Davi
- Section of Endocrinology, Medicina Generale e Malattie Aterotrombotiche e Degenerative, Department of Medicine, University of Verona, Piazzale LA Scuro, Policlinico G.B. Rossi, 37134, Verona, Italy.
| | - A Pia
- Internal Medicine I, Department of Clinical and Biological Sciences, University of Turin, San Luigi Hospital, Orbassano, Italy
| | - V Guarnotta
- Section of Endocrinology, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Palermo, Italy
| | - G Pizza
- Endocrinology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - A Colao
- Endocrinology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - A Faggiano
- Thyroid and Parathyroid Surgery Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione G. Pascale" IRCCS, Naples, Italy
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15
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Kim JR, Jang JY, Shin YC, Cho YM, Kim H, Kwon W, Han YM, Kim SW. Difficult diagnosis and localization of focal nesidioblastosis: clinical implications of (68)Gallium-DOTA-D-Phe(1)-Tyr(3)-octreotide PET scanning. Ann Surg Treat Res 2016; 91:51-5. [PMID: 27433465 PMCID: PMC4942539 DOI: 10.4174/astr.2016.91.1.51] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 03/23/2016] [Accepted: 04/12/2016] [Indexed: 11/30/2022] Open
Abstract
Focal nesidioblastosis is a rare cause of endogenous hyperinsulinemic hypoglycemia in adults. Because it is difficult to localize and detect with current imaging modalities, nesidioblastosis is challenging for biliary-pancreatic surgeons. 68Gallium-DOTA-D-Phe1-Tyr3-octreotide PET scanning and 111indium-pentetreotide diethylene triamine pentaacetic acid octreotide scanning may be superior to conventional imaging modalities in determining the localization of nesidioblastosis. We report the successful surgical treatment of a 54-year-old woman with focal hyperplasia of the islets of Langerhans, who experienced frequent hypoglycemic symptoms and underwent various diagnostic examinations with different results.
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Affiliation(s)
- Jae Ri Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Yong Chan Shin
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Young Min Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hongbeom Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Young Min Han
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sun-Whe Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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16
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Agrawal T, Blau AJ, Chwals WJ, Tischler AS. A Unique Case of Mediastinal Teratoma with Mature Pancreatic Tissue, Nesidioblastosis, and Aberrant Islet Differentiation: a Case Report and Literature Review. Endocr Pathol 2016; 27:21-4. [PMID: 26318442 DOI: 10.1007/s12022-015-9393-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Mediastinal teratomas with elements of mature pancreatic tissue are rare. Only a very few cases of pancreatic tissue with nesidioblastosis in teratoma have been reported. Here, we report a case of a 12-year-old male who presented with pleural effusion and was revealed to have a large anterior mediastinal mass. Biopsy of the mass revealed benign mature teratoma. After biopsy, the teratoma ruptured into the right thoracic cavity. It was then excised and sent to pathology for further evaluation. Preoperatively, there was no evidence of hyperinsulinemia or hypoglycemia. Postoperatively, there was no change in blood glucose levels. Histologically, the mass showed large areas of mature pancreatic tissue flanking a small intestine-like structure. Numerous endocrine cell islets, poorly defined groups of neuroendocrine cells and ductular-insular complexes characteristic of nesidioblastosis were dispersed in the exocrine pancreatic parenchyma. In addition, other parts of the tumor containing keratinizing squamous epithelium with cutaneous adnexal glands, small intestine, and bronchus including cartilage and respiratory epithelium were observed. Some islets contained two or more cell types while others were monophenotypic. Immunohistochemical staining showed pronounced expression of pancreatic polypeptide, moderate expression of somatostatin and insulin and nearly complete absence of glucagon-containing cells. The selective deletion of glucagon might hold clues to an important regulatory mechanism in pancreatic development.
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Affiliation(s)
- Tanupriya Agrawal
- Departments of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, MA, USA.
| | - Adam J Blau
- Department of Surgery, Tufts Medical Center, Boston, MA, USA
| | - Walter J Chwals
- Department of Pediatric Surgery, Tufts Medical Center, Boston, MA, USA
| | - Arthur S Tischler
- Departments of Pathology and Laboratory Medicine, Tufts Medical Center, Boston, MA, USA
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17
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Prasad V, Sainz-Esteban A, Arsenic R, Plöckinger U, Denecke T, Pape UF, Pascher A, Kühnen P, Pavel M, Blankenstein O. Role of (68)Ga somatostatin receptor PET/CT in the detection of endogenous hyperinsulinaemic focus: an explorative study. Eur J Nucl Med Mol Imaging 2016; 43:1593-600. [PMID: 26923247 DOI: 10.1007/s00259-016-3331-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 02/07/2016] [Indexed: 01/29/2023]
Abstract
PURPOSE To explore the role of (68)Ga-DOTATATE/DOTATOC PET/CT (SR PET/CT) in patients with suspicion of or histopathologically proven pancreatogenic hyperinsulinaemic hypoglycaemia. METHODS We included 13 patients with histopathologically proven or a high clinical suspicion of pancreatogenic hyperinsulinaemia. All the patients underwent a SR PET/CT scan. The results were correlated with histopathological findings. Normalization of blood glucose levels after resection of the pancreatic lesion, as well as a cytological and/or pathological diagnosis of insulinoma, was considered the diagnostic gold standard for insulinoma. The diagnosis of nesidioblastosis was based on exclusion of an insulinoma and conclusive pathological examination of a segment of the pancreas. Malignant insulinoma was defined as the presence of locoregional or distant metastases. RESULTS Based on histopathology, 13 patients were found to have pancreatic hyperinsulinaemia: two patients had malignant insulinoma, eight had nonmetastasized insulinoma, and three had nesidioblastosis. SR PET was positive in 11 of the 13 patients (84.6 %) with a final diagnosis of endogenous pancreatic hypoglycaemia. Histopathological staining confirmed 16 foci of hyperinsulinism (insulin positivity). SR PET detected 14 of the 16 lesions, resulting in a sensitivity of 87 %. One intrapancreatic spleen was falsely diagnosed as insulinoma focus on SR PET, resulting in positive predictive value of 93.3 %. Immunohistochemical staining of somatostatin receptor (SSR) subtype 2a was available in ten specimens: two nesidioblastosis, and seven benign and one malignant insulinoma. Eight out of the ten specimens (80 %) stained strongly to moderately positive. Seven of the eight SSR2a-positive lesions were picked up on SR PET. Based on the results of SR PET/CT, nine patients achieved complete remission of the hypoglycaemic events during follow-up. CONCLUSION This explorative study suggests that SR PET in combination with CT may play a significant role in the detection and management of patients with pancreatogenic hyperinsulinaemic hypoglycaemia. A large proportion of insulinomas express SSR2a, and a larger study is needed to fully assess the diagnostic accuracy of SR PET in patients with insulinoma and nesidioblastosis compared with current localizing studies used in clinical practice.
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Affiliation(s)
- Vikas Prasad
- Department of Nuclear Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany.
| | - Aurora Sainz-Esteban
- Department of Nuclear Medicine, Hospital Clínico Universitario Valladolid, Valladolid, Spain
| | - Ruza Arsenic
- Institute of Pathology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ursula Plöckinger
- Interdisziplinären Stoffwechsel-Centrum, Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Timm Denecke
- Department of Radiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrich-Frank Pape
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Andreas Pascher
- Department of General, Visceral and Transplant Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Kühnen
- Institute for Experimental Paediatric Endocrinology, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Marianne Pavel
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Oliver Blankenstein
- Institute for Experimental Paediatric Endocrinology, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
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18
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Abstract
Obesity is a major public health problem worldwide. Obesity-related illnesses, such as coronary heart disease, type 2 diabetes, hypertension, dyslipidemia, stroke, sleep apnea, and several forms of cancer (endometrial, breast, and colon), contribute to a significant number of deaths in the USA. Bariatric surgery, including the Roux-en-Y gastric bypass (RYGB) procedure, has demonstrated significant improvements in obesity and obesity-related co-morbidities and is becoming more popular as the number of obese individuals rises. Despite the reported benefits of bariatric surgery, there are potential complications that physicians need to be aware of as the number of patients undergoing these procedures continues to increase. One challenging and potentially life-threatening complication that to date is not well understood is post-RYGB surgery hypoglycemia (PGBH). In this review, we will present the definition, historical perspective, diagnostic approach, currently available treatment options, and anecdotal assessment and treatment algorithm for this disorder.
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Affiliation(s)
- Chevon M Rariy
- Division of Endocrinology, Diabetes, and Metabolism, University of Pittsburgh Medical Center (UPMC), 200 Lothrop Avenue, Pittsburgh, PA, 15225, USA.
- University of Pittsburgh School of Medicine, 200 Lothrop Avenue, Pittsburgh, PA, 15225, USA.
| | - David Rometo
- Division of Endocrinology, Diabetes, and Metabolism, University of Pittsburgh Medical Center (UPMC), 200 Lothrop Avenue, Pittsburgh, PA, 15225, USA.
- University of Pittsburgh School of Medicine, 200 Lothrop Avenue, Pittsburgh, PA, 15225, USA.
| | - Mary Korytkowski
- Division of Endocrinology, Diabetes, and Metabolism, University of Pittsburgh Medical Center (UPMC), 200 Lothrop Avenue, Pittsburgh, PA, 15225, USA.
- University of Pittsburgh School of Medicine, 200 Lothrop Avenue, Pittsburgh, PA, 15225, USA.
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19
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Malik S, Mitchell JE, Steffen K, Engel S, Wiisanen R, Garcia L, Malik SA. Recognition and management of hyperinsulinemic hypoglycemia after bariatric surgery. Obes Res Clin Pract 2015; 10:1-14. [PMID: 26522879 DOI: 10.1016/j.orcp.2015.07.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 06/17/2015] [Accepted: 07/06/2015] [Indexed: 02/06/2023]
Abstract
Hyperinsulinemic hypoglycemia with neuroglycopenia is an increasingly recognized complication of Roux-en-Y gastric bypass (RYGB) due to the changes in gut hormonal milieu. Physicians should be aware of this complication to ensure timely and effective treatment of post-RYGB patients, who present to them with hypoglycemic symptoms. Possible causes of hypoglycemia in these patients include late dumping syndrome, nesidioblastosis and rarely insulinoma. Systematic evaluation including history, biochemical analysis, and diagnostic testing might help in distinguishing among these diagnoses. Continuous glucose monitoring is also a valuable tool, revealing the episodes in the natural environment and can also be used to monitor treatment success. Treatment should begin with strict low carbohydrate diet, followed by medication therapy. Therapy with diazoxide, acarbose, calcium channel blockers and octreotide have been proven to be beneficial, but the response apparently is highly variable. When other treatment options fail, surgical options can be considered.
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Affiliation(s)
- Sarah Malik
- Neuropsychiatric Research Institute, Fargo, ND, United States; University of North Dakota School of Medicine and Health Sciences, Fargo, ND, United States
| | - James E Mitchell
- Neuropsychiatric Research Institute, Fargo, ND, United States; University of North Dakota School of Medicine and Health Sciences, Fargo, ND, United States.
| | - Kristine Steffen
- Neuropsychiatric Research Institute, Fargo, ND, United States; North Dakota State University, United States
| | - Scott Engel
- Neuropsychiatric Research Institute, Fargo, ND, United States; University of North Dakota School of Medicine and Health Sciences, Fargo, ND, United States
| | | | | | - Shahbaz Ali Malik
- University of North Dakota School of Medicine and Health Sciences, Fargo, ND, United States
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20
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Ramírez-González LR, Sotelo-Álvarez JA, Rojas-Rubio P, Macías-Amezcua MD, Orozco-Rubio R, Fuentes-Orozco C. [ Nesidioblastosis in the adult: a case report]. CIR CIR 2015; 83:324-8. [PMID: 26118781 DOI: 10.1016/j.circir.2015.05.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 08/21/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND Nesidioblastosis is a rare cause of endocrine disease which represents between 0.5% - 5% of cases. This has been associated with other conditions, such as in patients previously treated with insulin or sulfonylurea, in anti-tumour activity in pancreatic tissue of patients with insulinoma, and in patients with other tumours of the Langerhans islet cells. In adults it is presented as a diffuse dysfunction of β cells of unknown cause. CLINICAL CASE The case concerns 46 year-old female, with a history of Sheehan syndrome of fifteen years of onset, and with repeated events characterized with hypoglycaemia in the last three years. Body scan was performed with octreotide, revealing an insulinoma in the pancreatic region. A distal pancreatectomy was performed on the patient. The study reported a pancreatic fragment 8.5 × 3 × 1.5 cm with abnormal proliferation of pancreatic islets in groups of varying size, some of them in relation to the ductal epithelium. Histopathology study was showed positive for chromogranin, confirmed by positive synaptophysin, insulin and glucagon, revealing islet hyperplasia with diffuse nesidioblastosis with negative malignancy. The patient is currently under metabolic control and with no remission of hypoglycaemic events. CONCLUSIONS Nesidioblastosis is a disease of difficult diagnosis should be considered in all cases of failure to locate an insulinoma, as this may be presented in up to 4% of persistent hyperinsulinaemic hypoglycaemia.
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21
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Woo CY, Jeong JY, Jang JE, Leem J, Jung CH, Koh EH, Lee WJ, Kim MS, Park JY, Lee JB, Lee KU. Clinical features and causes of endogenous hyperinsulinemic hypoglycemia in Korea. Diabetes Metab J 2015; 39:126-31. [PMID: 25922806 PMCID: PMC4411543 DOI: 10.4093/dmj.2015.39.2.126] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 07/24/2014] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Endogenous hyperinsulinemic hypoglycemia (EHH) is characterized by an inappropriately high plasma insulin level, despite a low plasma glucose level. Most of the EHH cases are caused by insulinoma, whereas nesidioblastosis and insulin autoimmune syndrome (IAS) are relatively rare. METHODS To evaluate the relative frequencies of various causes of EHH in Korea, we retrospectively analyzed 84 patients who were diagnosed with EHH from 1998 to 2012 in a university hospital. RESULTS Among the 84 EHH patients, 74 patients (88%), five (6%), and five (6%) were diagnosed with insulinoma, nesidioblastosis or IAS, respectively. The most common clinical manifestation of EHH was neuroglycopenic symptoms. Symptom duration before diagnosis was 14.5 months (range, 1 to 120 months) for insulinoma, 1.0 months (range, 6 days to 7 months) for nesidioblastosis, and 2.0 months (range, 1 to 12 months) for IAS. One patient, who was diagnosed with nesidioblastosis in 2006, underwent distal pancreatectomy but was later determined to be positive for insulin autoantibodies. Except for one patient who was diagnosed in 2007, the remaining three patients with nesidioblastosis demonstrated severe hyperinsulinemia (157 to 2,719 µIU/mL), which suggests that these patients might have had IAS, rather than nesidioblastosis. CONCLUSION The results of this study suggest that the prevalence of IAS may be higher in Korea than previously thought. Therefore, measurement of insulin autoantibody levels is warranted for EHH patients, especially in patients with very high plasma insulin levels.
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Affiliation(s)
- Chang-Yun Woo
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Yun Jeong
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Eun Jang
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Jaechan Leem
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Hee Jung
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Hee Koh
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Woo Je Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Seon Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Joong-Yeol Park
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Bok Lee
- Department of Statistics, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Up Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
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de Santibañes M, Cristiano A, Mazza O, Grossenbacher L, de Santibañes E, Sánchez Clariá R, Sivori E, García Mónaco R, Pekolj J. Endogenous hyperinsulinemic hypoglycemia syndrome: surgical treatment. Cir Esp 2014; 92:547-52. [PMID: 24491350 DOI: 10.1016/j.ciresp.2013.04.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 04/15/2013] [Accepted: 04/28/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND The endogenous hyperinsulinemic hypoglicemia syndrome (EHHS) can be caused by an insulinoma, or less frequently, by nesidioblastosis in the pediatric population, also known as non insulinoma pancreatic hypoglycemic syndrome (NIPHS) in adults. The aim of this paper is to show the strategy for the surgical treatment of ehhs. MATERIAL AND METHODS A total of 19 patients with a final diagnosis of insulinoma or NIPHS who were treated surgically from january 2007 until june 2012 were included. We describe the clinical presentation and preoperative work-up. Emphasis is placed on the surgical technique, complications and long-term follow-up. RESULTS All patients had a positive fasting plasma glucose test. Preoperative localization of the lesions was possible in 89.4% of cases. The most frequent surgery was distal pancreatectomy with spleen preservation (9 cases). Three patients with insulinoma presented with synchronous metastases, which were treated with simultaneous surgery. There was no perioperative mortality and morbidity was 52.6%. Histological analysis revealed that 13 patients (68.4%) had benign insulinoma, 3 malignant insulinoma with liver metastases and 3 with a final diagnosis of SHPNI. Median follow-up was 20 months. All patients diagnosed with benign insulinoma or NIPHS had symptom resolution. CONCLUSION The surgical treatment of EHHS achieves excellent long-term results in the control of hypoglucemic symptoms.
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Affiliation(s)
- Martín de Santibañes
- Sector de Cirugía Hepato-Bilio-Pancreática y Trasplante Hepático, Departamento de Cirugía General, Hospital Italiano de Buenos Aires (HIBA), Buenos Aires, Argentina.
| | - Agustín Cristiano
- Sector de Cirugía Hepato-Bilio-Pancreática y Trasplante Hepático, Departamento de Cirugía General, Hospital Italiano de Buenos Aires (HIBA), Buenos Aires, Argentina
| | - Oscar Mazza
- Sector de Cirugía Hepato-Bilio-Pancreática y Trasplante Hepático, Departamento de Cirugía General, Hospital Italiano de Buenos Aires (HIBA), Buenos Aires, Argentina
| | - Luis Grossenbacher
- Sector de Endocrinología, Departamento de Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Eduardo de Santibañes
- Sector de Cirugía Hepato-Bilio-Pancreática y Trasplante Hepático, Departamento de Cirugía General, Hospital Italiano de Buenos Aires (HIBA), Buenos Aires, Argentina
| | - Rodrigo Sánchez Clariá
- Sector de Cirugía Hepato-Bilio-Pancreática y Trasplante Hepático, Departamento de Cirugía General, Hospital Italiano de Buenos Aires (HIBA), Buenos Aires, Argentina
| | - Enrique Sivori
- Sector de Cirugía Hepato-Bilio-Pancreática y Trasplante Hepático, Departamento de Cirugía General, Hospital Italiano de Buenos Aires (HIBA), Buenos Aires, Argentina
| | - Ricardo García Mónaco
- Sector de Angiografía y Radiología Intervencionista, Departamento de Diagnóstico por Imágenes, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan Pekolj
- Sector de Cirugía Hepato-Bilio-Pancreática y Trasplante Hepático, Departamento de Cirugía General, Hospital Italiano de Buenos Aires (HIBA), Buenos Aires, Argentina
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23
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Mala T. Postprandial hyperinsulinemic hypoglycemia after gastric bypass surgical treatment. Surg Obes Relat Dis 2014; 10:1220-5. [PMID: 25002326 DOI: 10.1016/j.soard.2014.01.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 01/09/2014] [Accepted: 01/14/2014] [Indexed: 12/15/2022]
Abstract
An association between post-Roux-en-Y gastric bypass (RYGB) hypoglycemia and nesidioblastosis was reported in 2005 and may cause serious neuroglycopenic symptoms. Most patients with postprandial hypoglycemia after RYGB respond to nutritional and medical treatment. A subset of patients, however, may not respond adequately and surgery may be considered. This review describes the current experience with surgical intervention for severe post-RYGB hypoglycemia. PubMed and MEDLINE searches were made for reports describing clinical outcome after such surgery. Fourteen papers including 75 patients were identified. Different surgical interventions were applied including gastric tube placement, reversal of the bypass with and without concomitant sleeve resection, gastric pouch restriction, and pancreatic resection and reresection. Pancreatic resection was performed in 51 (68%) patients, 17 (23%) had RYGB reversal and eleven (15%) had gastric pouch restriction alone. Eight (11%) patients received 2 or more consecutive procedures for hypoglycemia and combined interventions were made in several patients. Resolution of the symptoms occurred in 34/51 (67%) patients after pancreatic resection, 13/17 (76%) after reversal, and 9/11 (82%) after pouch restriction. Mean follow up, however, was short for most series and the methods applied for evaluation of hypoglycemia varied. Weight regain, diabetes and recurrent symptoms were late complications. The optimal therapy for hypoglycemia after RYGB is not defined. Long-term evaluations and knowledge about the physiology of post-RYGB hypoglycemia, may enable therapy with improved control of the glucose excursions.
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Affiliation(s)
- Tom Mala
- Department of Morbid Obesity and Bariatric Surgery/Department of Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway.
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24
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Redkar R, Karkera PJ, Krishnan J, Hathiramani V. Subtotal Pancreatectomy for Congenital Hyperinsulinism: Our Experience and Review of Literature. Indian J Surg 2015; 77:778-82. [PMID: 27011456 DOI: 10.1007/s12262-013-0999-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Accepted: 10/20/2013] [Indexed: 01/24/2023] Open
Abstract
Congenital hyperinsulinism (HI) is characterized by profound hypoglycemia caused by inappropriate insulin secretion. HI is a heterogeneous disorder with at least two histologic lesions and several implicated genes. If HI is caused by a focal lesion, elective surgery is the treatment of choice because it leads to complete recovery without diabetes. On the contrary, near-total pancreatectomy though recommended for diffuse HI, long-term risks of endocrine and exocrine deficiencies are present. Between the years 2006-2011, three patients of HI were referred to and operated by a single surgeon. The preoperative diagnosis was confirmed by recurrent hypoglycemia, inappropriately high insulin levels, and augmented glucose requirements. The medical records of all three patients were reviewed to study their clinical features, medical and surgical treatment, and postoperative outcome (short- and long-term). There were three patients in this series (male/female ratio, 1:2), all presenting in the neonatal age. All patients failed medical treatment, and radiological imaging did not reveal any pancreatic lesion. All patients underwent subtotal (80 %) pancreatectomy. Two patients had diffuse type of HI and one focal HI. One patient had transient hyperglycemia for 3 months, which needed insulin supplementation. No patient has developed recurrent hypoglycemia, malabsorption syndrome, or any neurological sequelae until the last follow-up. Doing subtotal or near-total pancreatectomy in diffuse type of HI still remains controversial as one has a higher risk of recurrent hypoglycemia, while the other has a higher rate of insulin dependent diabetes mellitus. Subtotal (80 %) pancreatectomy may be considered as the primary modality of surgical intervention in diffuse type of HI, especially when the diagnostic facilities are limited or diagnosis is not known after preliminary investigations. This minimizes the chances of postoperative diabetes mellitus, and redo surgery can always be considered if there is recurrent hypoglycemia.
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García-Santos EP, Manzanares-Campillo MDC, Padilla-Valverde D, Villarejo-Campos P, Gil-Rendo A, Muñoz-Atienza V, Sánchez-García S, Puig-Rullán AM, Rodríguez-Peralto JL, Martín-Fernández J. Nesidioblastosis. A case of hyperplasia of the islets of Langerhans in the adult. Pancreatology 2013; 13:544-8. [PMID: 24075522 DOI: 10.1016/j.pan.2013.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 06/02/2013] [Accepted: 06/27/2013] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Nesidioblastosis is a rare disease caused by hyperplasia of pancreatic islets, developing a state of hypoglycemia due to an increase in the insulin production. It is the leading cause of hyperinsulinic hypoglycemia in childhood, whereas in adults it only represents the 0.5-5% of cases. The pathogenesis is still unknown. We have studied several genetic mutations associated with dependent potassium channel of ATP present in the beta cells of the pancreas, as well as in patients underwent bariatric surgery because of the metabolic changes involved. REPORT Woman (38 years old) attends consultation of General Surgery derived from Endocrinology before symptoms of persistent hypoglycemia. Factitious hypoglycemia and syndromes of neuroendocrine origin were ruled out. Imaging tests failed to identify space-occupying lesions. The medical treatment failed, persisting hypoglycemia symptoms. Before the given analytical and radiological findings obtained, and the persistence of symptoms affecting the quality of life of the patient, we opted for surgical treatment performing a pancreatectomy of the 80% of the gland. The final pathologic diagnosis was nesidioblastosis. DISCUSSION Nesidioblastosis is a rare pathology, but it must be present in the differential diagnosis of hypoglycemia symptoms with endogenous hyperinsulinism in adults, once the intake of sulfonylureas and possible pancreatic neoformations have been ruled out.
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Affiliation(s)
- Esther Pilar García-Santos
- Servicio de Cirugía General y de Aparato Digestivo, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain.
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Campos GM, Ziemelis M, Paparodis R, Ahmed M, Davis DB. Laparoscopic reversal of Roux-en-Y gastric bypass: technique and utility for treatment of endocrine complications. Surg Obes Relat Dis 2013; 10:36-43. [PMID: 24120983 DOI: 10.1016/j.soard.2013.05.012] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 04/24/2013] [Accepted: 05/25/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND The anatomic and physiologic changes with Roux-en-Y gastric bypass (RYGB) may lead to uncommon but occasionally difficult to treat complications such as hyperinsulinemic hypoglycemia with neuroglycopenia and recalcitrant hypocalcemia associated to hypoparathyroidism. Medical management of these complications is challenging. Laparoscopic reversal of RYGB anatomy with restoration of pyloric function and duodenal continuity is a potential treatment. The objective of this study was to present the indications, surgical technique, and clinical outcomes of laparoscopic reversal of RYGB. METHODS Prospective study of consecutive patients offered laparoscopic reversal of RYGB. RESULTS Five patients with remote laparoscopic RYGB underwent laparoscopic reversal of RYGB to normal anatomy (n = 2) or modified sleeve gastrectomy (n = 3). Indications were medically refractory hyperinsulinemic hypoglycemia with neuroglycopenia (n = 3), recalcitrant hypocalcemia with hypoparathyroidism (n = 1), and both conditions simultaneously (n = 1). Before reversal, all patients had a gastrostomy tube placed in the excluded stomach to document improvement of symptoms. Laparoscopic reversal was accomplished successfully in all patients. Three postoperative complications occurred: bleeding that required transfusion, gallstone pancreatitis, and a superficial trocar site infection. Average length of stay was 3 days. At a mean follow-up of 12 months (range 3 to 22), no additional episodes of neuroglycopenia occurred, average number of hypoglycemic episodes per week decreased from 18.5 ± 12.4 to 1.5 ± 1.9 (P = .05), and hypocalcemia became responsive to oral replacement therapy in both patients. CONCLUSIONS Laparoscopic reversal of RYGB to normal anatomy or modified sleeve gastrectomy is feasible and may be a therapeutic option for selected patients with medically refractory hyperinsulinemic hypoglycemia and/or recalcitrant hypocalcemia associated with hypoparathyroidism.
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Affiliation(s)
- Guilherme M Campos
- Department of Surgery, Division of General Surgery, Section of Foregut and Bariatric Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
| | - Martynas Ziemelis
- Department of Surgery, Division of General Surgery, Section of Foregut and Bariatric Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Rodis Paparodis
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Muhammed Ahmed
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Dawn Belt Davis
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
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Maeda Y, Yokoyama K, Takeda K, Takada J, Hamada H, Hujioka Y, Kudo SE. Adult-onset diffuse nesidioblastosis causing hypoglycemia. Clin J Gastroenterol 2013; 6:50-4. [PMID: 26181405 DOI: 10.1007/s12328-012-0335-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 09/27/2012] [Indexed: 11/27/2022]
Abstract
We report the case of a 32-year-old male with adult-onset diffuse nesidioblastosis causing hypoglycemia. Under the tentative diagnosis of insulinoma, localization procedures were carried out but no tumor was found. The presence of an insulinoma in the tail of the pancreas was suggested by selective intra-arterial calcium stimulation with hepatic venous sampling (ASVS). A distal pancreatectomy was performed under the assumed diagnosis of insulinoma in the tail based upon the ASVS. Diffuse nesidioblastosis was diagnosed by histopathological evaluation. During the post-operative course, the patient's glucose and insulin levels were well controlled and uneventful without any medications or insulin for 7 months.
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Affiliation(s)
- Yasuharu Maeda
- Department of Gastroenterology, Nikko Memorial Hospital, Muroran, Japan. .,Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohoma, Japan.
| | - Kazunori Yokoyama
- Department of Gastroenterology, Nikko Memorial Hospital, Muroran, Japan
| | - Kenichi Takeda
- Department of Gastroenterology, Nikko Memorial Hospital, Muroran, Japan.,Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohoma, Japan
| | - Jyouji Takada
- Department of Surgery, Nikko Memorial Hospital, Muroran, Japan
| | - Hiromi Hamada
- Department of Surgery, Nikko Memorial Hospital, Muroran, Japan
| | - Yasunori Hujioka
- Department of Pathology, Nikko Memorial Hospital, Muroran, Japan
| | - Shin-Ei Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohoma, Japan
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Abstract
Pathologic hyperplasia of various pancreatic endocrine cells is rare but has been long known. β cell hyperplasia contributes to persistent hyperinsulinemic hypoglycemia of infancy, which is commonly caused by mutations in the islet ATP-sensitive potassium channel, and to non-insulinoma pancreatogenous hypoglycemia in adults, which may or may not be associated with bariatric surgery. α cell hyperplasia may cause glucagonoma syndrome or induce pancreatic neuroendocrine tumors. An inactivating mutation of the glucagon receptor causes α cell hyperplasia and asymptomatic hyperglucagonemia. Pancreatic polypeptide cell hyperplasia has been described without a clearly-characterized clinical syndrome and hyperplasia of other endocrine cells inside the pancreas has not been reported to our knowledge. Based on morphological evidence, the main pathogenetic mechanism for pancreatic endocrine cell hyperplasia is increased endocrine cell neogenesis from exocrine ductal epithelium. Pancreatic endocrine cell hyperplasia should be considered in the diagnosis and management of hypoglycemia, elevated islet hormone levels, and pancreatic neuroendocrine tumors. Further studies of pathologic pancreatic endocrine cell hyperplasia will likely yield insights into the pathogenesis and treatment of diabetes and pancreatic neuroendocrine tumors.
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