Diabetes Pancreatitis Flashcards
What are the exocrine functions of the pancreas?
Acinar cells secrete pancreatic enzymes into pancreatic duct
What are the endocrine functions of the pancrase?
IN
islets of langerhan cells secrete hormones into the blood vessels
What are the digestive functions of the exocrine pancreas?
Secretes alkaline fluid containing bicarbonate and digestive enzymes that assist in absorption of nutrients and digestion in the small intestine
What enzymes are produced/secreted by acinar cells?
– Amylolytic enzymes:
• Hydrolyze starch
• AMYLASE
– Lipolytic enzymes:
• Include LIPASE,phospholipaseA2,cholesterolesterase
– Proteolytic enzymes:
• ELASTASE,trypsin,chymotrypsin,carboxypeptidases,aminopeptidases
What are hte multiple hormones that the endocrine pancreas makes to regulate glucose homeostasis?
insulin
glucagon
somatostatin
insulin (HIGH GLUCOSE)
glucose stimulates BETA cells to secrete insulin
glucagon (LOW GLUCOSE)
low insulin/blood glucose stimulates ALPHA cells to produce glucagon that stimulates glycogenolysis/gluconoeogenesis
somatostatin
deta cells –> STT –> inhibits both insulin and glucagon secretion
How is hte insluin molecule formed?
Preproinsulin (contains signal peptide and c peptide) >
pro insulin (c peptide) >
insulin (just A and B chains)
Describe insulin biogenesis?
Reserve pool and RRP
What happens when insluin is realsed from readily releasable pools followed by reserve pools?
biphasic insulin release
What counterregulates glucose when it is low (sxs seen when glucose is < 55)?
Glucagon epinephrine growth hormone cortisol imparied cognition
A 45 year old female nurse presents to the ER with confusion, palpitations and diaphoresis.
• Labs:
– Random plasma glucose: 40 mg/dL
What is the definition of hypoglycemia?
• Depends on whether the patient has diabetes
• In diabetics:
– ADA recommended there should be concern about the
possibility of hypoglycemia if ≤ 70 mg/dL
– Higher than cut‐off for non‐diabetics, reflecting concern that diabetics may have repeated hypoglycemic episodes related to treatment
• In non‐diabetics:
– Hypoglycemia should not be diagnosed solely on the basis of a glucose level unless it is severely depressed (<40 mg/dL
– That being said, symptoms usually kick in for non‐diabetics ≤ 55 mg/dL
– Only patients with Whipple’s triad should be evaluated for a hypoglycemic disorder
What is whipple’s triad?
Whipple’striad: Whipple triad is the clinical presentation of PANCREATIC INSULINOMA and consists of:
1. fasting hypoglycemia (<50 mg/dl)
2. symptoms of hypoglycemia
3. Immediate relief of symptoms after the administration of IV glucose.
– Recognize that the patient’s symptoms could be caused by hypoglycemia
– Document that the patient’s plasma glucose concentrations are low when the symptoms are present
– Show that the symptoms can be relieved by administration of glucose
• If it is possible, order a 2nd random plasma glucose before glucose infusion to confirm result
– However if clinical situation is urgent do NOT delay glucose infusion for a second measurement
What is the most common ddx for hypoglycemia?
• Diabetes mellitus
– Due to exogenous insulin or an insulin secretagogue (i.e. sulfonylurea or glinide)
• Drug induced
– MOST common cause of hypoglycemia
– 164 drugs associated with hypoglycemia
– Seen with quinolones, pentamidine, quinine, beta blockers, ACE inhibitors, IGF‐1, others
– Alcohol:
• Inhibits gluconeogenesis but not glycogenolysis
• Typically happens after a several‐day binge with limited food ingestion resulting in hepatic glycogen depletion
What are less common causes of hypoglycemia?
• Endogenous hyperinsulinism: – Insulinoma
– Sulfonylurea/glinide use
– Nesidioblastosis
– Insulin autoimmune hypoglycemia
• Antibodies to insulin or insulin receptor
• Accidental, malicious or surreptitious hypoglycemia:
– Suspect with children (Munchausen’s by proxy), health care workers,
spouses of diabetics, pharmacy or medical error • Pseudohypoglycemia:
– Ifcollectiontubedoesnothaveaninhibitorofglycolysis,glucosecan lower by 10 mg/dL per hour in the tube
– Shouldbemeasuredfromagray‐toptube(withNaF) • Other:
– Non‐islet cell tumors, cortisol deficiency, malnourishment, critical illness
After Whipple’s triad is confirmed, what additional tests should be ordered, and why?
Additional tests: – Insulin – C‐peptide – Proinsulin – Sulfonylurea and glinide screen – Beta‐hydroxybutyrate
•Once patient is treated and asymptomatic, she should undergo a supervised fast until symptom recurrence, or until 72 hours elapse
How do you interpret these lab results measured during a 72 hour fast?
• Glucose 40 mg/dL
• Insulinlevel: 12mU/L
– Reference range: up to 20 mU/L when fasting
– However, if glucose < 55 mg/dL insulin should be < 3 mU/L
• C‐peptidelevel: 2.9ng/mL
– Reference range: 0.8‐4 ng/mL when fasting
– However, if glucose < 55 mg/dL, C‐peptide should be < 0.6 ng/mL
• ThereforebothinsulinandC‐peptideare inappropriately normal (high for the situation)
What causes endogenous hyperinsulinemia?
- Sulfonylurea/glinide use
- Insulinoma
- Autoimmune hypoglycemia mediated by insulin antibodies
- Noninsulinoma pancreatogenous hypoglycemia syndrome
- Post gastric bypass hypoglycemia
Insluinoma -elevated insluine and high c peptide
What is seen with exogenous hyperinsulinemia?
elevation of insulin level and low c peptide
What are hte current diagnostic criteria for diabetes?
- Fasting plasma glucose ≥ 126 mg/dL
- HbA1C ≥ 6.5%
- 2 hour value in an OGTT ≥ 200 mg/dL
- Random plasma glucose concentration ≥ 200 mg/dL with symptoms
Does repeat testing of this patient’s plasma glucose need to be performed to confirm a diagnosis of diabetes? Why or why not?
- if the pt has unequivocal symptomatic hyperglycemia a subsequent measurement is NOT required
- in the absence of CLEAR SXS a repeat test is required
- if two different tests (RPG and A1C) are available then concordant repeat testing is NTO required regardless of sxs
- if two tests are discordant the test that is diagnostic of diabetes shoiuld be repeated to confirm the diagnosis
