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AIP: Diabetic emergencies > Other causes of hypoglycaemia > Flashcards

Other causes of hypoglycaemia Flashcards

1
Q

In addition to iatrogenic causes of hypoglycaemia related to diabetes, what are 5 further causes of hypoglycaemia?

A
  1. Addison’s disease
  2. Insulinoma
  3. Mesenchymal tumours (e.g. Non-Islet Cell Tumour Hypoglycaemia NICTH)
  4. Factitious hypoglycaemia
  5. Reactive hypoglycaemia
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2
Q

How can Addison’s disease cause hypoglycaemia?

A
  • as there are many hyperglycemic hormones (glucagon, growth hormone, adrenaline), a cortisol deficiency is not likely to produce hypoglycemia unless fasting occurs or the person is stressed
  • Cortisol is essential for proper mobilization of proteins for glucose production - under stress hypoglycaemia can therefore occur
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3
Q

What is Addison’s disease?

A

a primary adrenal insufficiency in which the levels of both mineralocorticoids (aldosterone) and glucocorticoids (cortisol) are usually extremely low

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4
Q

What is the most common cause of Addison’s disease in the developed world?

A

autoimmune adrenal deustruction (90% of cases)

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5
Q

Which gender is predominantly affected by Addison’s disease?

A

women (2-3:1 F:M)

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6
Q

What are 7 causes of Addison’s disease additional to autoimmune?

A
  1. Infections - tuberculosis commonest cause worldwide
  2. Adrenal haemorrhage/infarction (in sepsis: Waterhouse-Friderichsen syndrome)
  3. Metastatic carcioma (breast and lung)
  4. Infiltrative causes: sarcoidosis, amyloidosis and haemochromatosis
  5. Inherited disorders
  6. Iatrogenic - surgery, bilateral nephrectomies
  7. Trauma
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7
Q

What predominantly causes the symptoms and signs of Addison’s disease?

A

cortisol deficiency

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8
Q

What are 6 symptoms of Addison’s disease?

A
  1. Lethargy
  2. GI symptsom: abdominal pain, nausea, vomiting, diarrhoea
  3. Skeletal muscle weakness, fatigue
  4. Orthostatic dizziness (postural hypotension)
  5. Weight loss
  6. Increase in pigmentation
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9
Q

What causes increased skin pigmentation in Addison’s disease?

A

increased levels of ACTH due to adrenal insufficiency; the other product when the precursor of ACTH, pro-opiomelanocortin, is cleaved is beta-lipotrophin

beta-lipotrophin stimulates melanocytes to produce melanin

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10
Q

What is Addisonian crisis?

A

sudden-onset adrenal failure e.g. haemorrhage, or caused by increased cortisol requirements (concurrent infection, surgery, trauma)

leads to hypovolaemic shock, often with acidosis and hypoglycaemia

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11
Q

What are 7 key investigations in Addison’s disease and the likely findings?

A
  1. Serum cortisol concentration: low
  2. Adrenal autoantibodies: against 21-hydroxylase, in 50% of patients
  3. Serum ACTH: raised
  4. Serum electrolytes: hyponatraemia, hyperkalaemia, raised urea
  5. Glucose level: hypoglycaemia may occur
  6. Short and long synacthen tests: positive
  7. Screening for other autoimmune diseases e.g. thyroid
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12
Q

What is the definitive investigation in suspected Addison’s disease?

A

ACTH stimulation test: short synacthen test

plasma cortisol measured before and 30min after giving Synacthen 250 ug IM

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13
Q

What are the 4 key electrolytes abnormalities seen in Addison’s patients?

A
  1. Hyperkalaemia
  2. Hyponatraemia
  3. Hypoglycaemia
  4. Metabolic acidosis
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14
Q

What are the 3 key aspects of the management of Addison’s disease?

A
  1. Glucocorticoid and mineralocortoid replacement therapy:
    • hydrocortisone, 20-30mg per day in 2-3 divided doses, most in first half of day
    • fludrocortisone
  2. Patient education
  3. Management of intercurrent illness
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15
Q

What are 4 aspects of patient education in Addison’s disease?

A
  1. importance of not missing glucocorticoid doses
  2. consider MedicAlert bracelets/ steroid cards
  3. provide with hydrocortisone for injection with needles and syringes to treat an adrenal crisis
  4. discuss how to adjust the glucocorticoid dose during an intercurrent illness
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16
Q

In simple terms what is the management of Addison’s disease during intercurrent illness?

A

glucocorticoid dose should be doubled

17
Q

What is an insulinoma?

A

neuroendocrine tumour deriving mainly from pancreatic islet of Langerhans cells. most common pancreatic endocrine tumour

18
Q

What proportion of insulinomas are 1. malignant and 2. multiple at once occur?

A
  1. 10%
  2. 10%
19
Q

Of patients with multiple insulinoma tumours, what proportion have MEN-1 (multiple endocrine neuroplasia type 1)?

A

50%

20
Q

What are 4 key clinical features of insulinoma?

A
  1. hypoglycaemia: typically early in morning or just before meal e.g. diplopia, weakness, sweating, palpitations, confusion, grand mal seizures, tremor
  2. rapid weight gain
  3. high insulin, raised proinsulin: insulin ratio
  4. high C-peptide
21
Q

What are 2 key investigations to make a diagnosis of insulinoma?

A
  1. Supervised, prolonged fasting (up to 72 h)
  2. CT pancreas
22
Q

What are 4 key aspects of the management of insulinoma?

A
  1. Surgical removal - enucleation of single insulinoma, partial pancreatectomy for multiple

if not candidates for surgery:

  1. Diazoxide: inhibits insulin release, enhances glycogenolysis
  2. Lanreotide and octreotide - somatostatin analogues
  3. Streptozotocin - toxic to insulin-producing beta cells
23
Q

What are 3 ways that factitious hypoglycaemia can arise?

A
  1. Intentionally as diagnostic tool
  2. Accidentally as complication of treatment of DM
  3. Consequence of poisoning either with insulin itself or with drugs e.g. sulfonylureas that stimulate insulin release
24
Q

In children whenever severe hypoglycaemia occurs with documented hyperinsulinism, what diagnosis must be considered?

A

Munchausen syndrome by proxy

25
Q

What possibiliy should be considered in the case of sudden onset hypoglycaemia in a previously healthy individual?

A

possibility of malicious administration of insulin or an oral sulfonylurea

26
Q

What is the clue in the biochemistry pointing towards a diagnosis of factitious hypoglycaemia?

A

raised insulin level accompanied by normal C-peptide

27
Q

What are 4 causes of reactive hypoglycaemia?

A
  1. Insulin-induced
  2. Drug-induced e.g. sulfonylreas
  3. Alcohol
  4. Dumping syndrome - accelerated gastric emptying following gastric resection e.g. gastric bypass for weight loss, may result in rapid absorption of large amounts of glucose with surge of insulin release
28
Q

What is C-peptide?

A

pro-insulin molecule breaks up into insulin and C-peptide

29
Q

What are 3 mechanisms of alcohol causing hypoglycaemia?

A
  1. Malnutrition
  2. Inhibition of gluconeogenesis
  3. Liver disease
30
Q

What can help to minimise hypoglycaemia when caused by Dumping syndrome?

A

smaller, more frequent meals and avoidance of large amounts of sugars

AIP: Diabetic emergencies (5 decks)

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