Foppiani Luca, Panarello Serena, Filauro Marco, Scirocco Maria Concetta, Cappato Stefano, Parodi Andrea, Sola Simona, Antonucci Giancarlo
Department of Internal Medicine, Galliera Hospital, Genova, Italy.
Department of Surgery, Galliera Hospital, Genova, Italy.
Clin Med Insights Endocrinol Diabetes. 2017 Nov 20;10:1179551417742620. doi: 10.1177/1179551417742620. eCollection 2017.
A hypertensive man with chronic kidney disease (CKD) secondary to polycystic disease was hospitalized for symptoms related to hypoglycemia. Fasting test elicited symptomatic hypoglycemia after 12 hours, which was associated with inappropriately unsuppressed normal insulin and C-peptide levels. Neither ultrasonography (US) nor magnetic resonance imaging detected any pancreatic tumor. Endoscopic ultrasonography (EUS) showed a small isoechogenic nodule suspect for neuroendocrine tumor in the pancreatic head. Gallium-DOTA-Tyr-octreotide positron emission tomography/computed tomography revealed intense uptake by a small region in the pancreatic head. Surgical exploration together with intraoperative US confirmed the nodule in the pancreatic head and evidenced another hypoechogenic one in the uncinate process. Both nodules were enucleated, but only the latter, which had not been previously detected by EUS, proved compatible with insulinoma on combined histology and immunohistochemistry. After nodule enucleation, hypoglycemia resolved and did not relapse. Insulinoma, as a major cause of unexplained hypoglycemia, requires careful hormonal and instrumental workup. In patients with CKD, the interpretation of biochemical criteria for the diagnosis of insulinoma can be challenging. Localization techniques may display pitfalls. Surgery is curative in most patients but long-term follow-up is required.
一名患有多囊肾病继发慢性肾脏病（CKD）的高血压男性因低血糖相关症状入院。禁食试验在12小时后引发了症状性低血糖，这与正常胰岛素和C肽水平未得到适当抑制有关。超声检查（US）和磁共振成像均未检测到任何胰腺肿瘤。内镜超声检查（EUS）显示胰头有一个小的等回声结节，怀疑为神经内分泌肿瘤。镓-DOTA-酪氨酸-奥曲肽正电子发射断层扫描/计算机断层扫描显示胰头一个小区域有强烈摄取。手术探查及术中超声检查证实胰头有结节，并在钩突部发现另一个低回声结节。两个结节均被摘除，但只有后者（此前未被EUS检测到）经组织学和免疫组织化学联合检查证实为胰岛素瘤。结节摘除后，低血糖症状消失且未复发。胰岛素瘤作为不明原因低血糖的主要原因，需要进行仔细的激素和仪器检查。在CKD患者中，胰岛素瘤诊断的生化标准解读可能具有挑战性。定位技术可能存在缺陷。手术对大多数患者具有治愈性，但需要长期随访。
