pheochomocytoma and hypoglycemia - web (1)
TRANSCRIPT
PHEOCHROMOCYTOMA AND
HYPOGLYCEMIA
Lewis C. Weger, MPAS, PA-C
Principles of Clinical Medicine
OBJECTIVES Define Pheochromocytoma
Describe the Signs and Symptoms of Pheochromocytoma
Discuss the Work-up and Treatment of Pheochromocytoma
OBJECTIVES Define Hypoglycemia Discuss the Clinical Signs and
Symptoms of Hypoglycemia Discuss the Work-up and
Treatment of Hypoglycemia Discuss Reactive (Post-prandial)
Hypoglycemia Compare true Hypoglycemia to
Facticious Hypoglycemia
PHEOCHROMOCYTOMA
• Pheochromocytoma• Paroxysmal Hypertension in the
young to mid-adults predominantly
• Etiology• Tumor of the adrenal medulla (90%)– ~ 80% are unilateral and solitary– excess epinephrine production– excess Norepinephrine production– ~ 10% of tumors are malignant– part of the MEN – II syndromes
PHEOCHROMOCYTOMA
• Signs and Symptoms• Paroxysmal
• Diagnostic Clues – SIX “H’s”•Hypertension
•Headache – throbbing (90%)
•Heart palpitations – (73%)
•Hyperhidrosis – (70%)
•Hypermetabolism
•Hyperglycemia
PHEOCHROMOCYTOMA
• Classic Presentation• Predominant Symptoms– H/A, Diaphoresis, Palpitations
•Associated Symptoms– Anxiety and tremor– Pallor and flushing (rare)– Chest and epigastric pain– Painless hematuria
• Timing of episodes– One hour or less – daily to months
PHEOCHROMOCYTOMA
• Diagnosis• Stop all questionable medications• Labs– Plasma Free Metanephrines• Sensitivity/Specificity (99%; 89%)
– Plasma Catecholamines• S/S (85%; 80%)
– 24-hour urine Metanephrines• S/S (76%; 94%)
– 24-hour Urine VMA• S/S (63%; 94%)
PHEOCHROMOCYTOMA
• Diagnosis•Radiology– Adrenal CT scan• S/S (93-100%; 70%)
– Adrenal MRI• S/S (same as CT)
– MIBG scan• Metaiodobenzyl-guanidine• Good for looking for tumors in
unusual places
PHEOCHROMOCYTOMA
• Management•Medical efforts before surgical
•Medical– Alpha Adrenergic Receptor
Antagonists• Phenoxybenzamine• Phentolamine
– Beta blocker AFTER Alpha!• Propanolol
• Surgical
HYPOGLYCEMIA
• Definition: A clinical syndrome of multiple etiologies that results in symptomatic or asymptomatic episodes of low blood glucose levels• Terminology such as “fasting”
or “reactive” (post-prandial) hypoglycemia is not really the best way to classify hypoglycemia
HYPOGLYCEMIA
• Traditional Classifications:• Reactive or Post-Prandial
– Symptoms follow several hours after eating
• Fasting– Symptoms associated with
lack of eating• Secondary
– Symptoms caused by other reasons than those listed above – meds, insulin, illness, disease, etc.
• Factitious– Malicious or intentional
ingestion of oral hypoglycemics or injection of insulin to produce hypoglycemic condition
HYPOGLYCEMIA
•New Thought Classifications:•Healthy Patient Hypoglycemia– consider all likely causes –
meds, medical conditions, drugs, insulinoma, etc.
•Sick or ill Patient Hypoglycemia– Consider all likely causes with
emphasis on the illness-based causes
HYPOGLYCEMIA
•Diagnosis:•Highly clinical in many instances
•Complete patient history
•Blood glucose level during symptomatic episode
HYPOGLYCEMIA
• Symptoms: A wide variety based upon two major categories•Autonomic•Neuroglycopenic
• Symptoms may vary between patients, but they usually are consistent between episodes in any particular patient
HYPOGLYCEMIA
•Autonomic•Diaphoresis
•Tremors
•Flushing
•Anxiety
•Nausea
HYPOGLYCEMIA
•Neuroglycopenic•Dizziness
•Mental confusion
•Fatigue
•Dysarthria
•Headache
•Poor concentration or amnesia
•Seizures
HYPOGLYCEMIA
•Mixed – symptoms that have components of both autonomic and neuroglycopenic •Hunger
•Blurred vision
•Drowsiness
•Weakness
HYPOGLYCEMIA
• Physical Exam•Usually normal by the time the
patient is seen by the medical provider
•May present with minor abnormalities
• Signs are not specific for hypoglycemia in healthy patients
• Signs in ill patients will reflect those signs associated with that illness
HYPOGLYCEMIA
• Etiology•Drugs – ETOH, Quinine, ASA, …
• Insulinomas – hyperinsulinism
•Metabolic conditions like:– Addison’s– Hypopituitarism– Renal Failure– Sepsis or shock– Starvation – anorexia nervosa– Many others – see table 339-1 & H/O
HYPOGLYCEMIA
• Laboratory evaluation•Serum Glucose – most important– normal result during symptomatic
episode effectively rules out hypoglycemia-based condition
•72-hour fast – classic test for dx– < 50mg/dL is termination point
•Beta cell polypeptides– Insulin, C-Peptide, Proinsulin– value varies in relation to glucose
HYPOGLYCEMIA• Laboratory evaluation• Sulfonylureas & Meglitinides– Beta cell polypeptide concentrations are
identical to that noted with an insulinoma rules out factitious etiology if pts are using these meds
• Insulin antibodies– High levels insulin autoimmune d/o– Low level factitious hypoglycemia
• C-Peptide suppression test– C-Peptide formed by conversion of proinsulin
to insulin– Low level exogenous source of insulin– High level insulinoma likely
HYPOGLYCEMIA• Insulinoma
•Diagnosis by:– patient history– insulin levels– US, Spiral CT, MRI of the abdomen –
especially the pancreas
• Treatment:– Surgery is the preferred method– Medical treatment (Diazoxide) may be
used for those patients who are not surgical candidates
HYPOGLYCEMIA•Reactive Hypoglycemia - • Etiology: Prolongation of the effect
of insulin as counter-regulatory mechanism is slow to shut off insulin
•Diagnosis by:– patient history!– insulin levels usually are normal– glucose level during episode – low
• Treatment:– Multiple small meals versus large meals– Mid morning and afternoon snack
HYPOGLYCEMIA• Factitious Hypoglycemia - • Etiology: Usually due to inappropriate
administration of hypoglycemic meds or insulin•Diagnosis by:– patient history!– insulin level during episode High – C-Peptide level during episode Low– glucose level during episode – Low– Sulfonylurea & Meglitinide level High,
if present• Treatment:– STOP offending agent!– Psych eval if deliberate covert use
CONCLUSION Defined Pheochromocytoma
Described the Signs and Symptoms of Pheochromocytoma
Discussed the Work-up and Treatment of Pheochromocytoma
CONCLUSION Defined Hypoglycemia Discussed the Clinical Signs and
Symptoms of Hypoglycemia Discussed the Work-up and
Treatment of Hypoglycemia Discussed Reactive (Post-
prandial) Hypoglycemia Compared true Hypoglycemia to
Factitious Hypoglycemia