Insulinoma diagnostic criteria

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]

Overview

The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].

OR

The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].

OR

The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].

OR

There are no established criteria for the diagnosis of [disease name].

Diagnostic Criteria

• The classical diagnosis of insulinoma is based on the Whipple's triad(1935), which includes:

1. Hypoglycemia( fasting blood glucose <50 mg/dL)
2. Symptoms of hypoglycemia
   • Neuroglycopenic- visual disturbances(blurring of vision, diplopia), confusion, weakness, behavioral changes, seizures and coma
   • Adrenergic-Sweating, palpitations, tremors and hyperphagia/obesity
3. Improvement of symptoms after glucose infusion

• The diagnosis of insulinoma is based on the Biochemical assay with RadioImmunoAssay(RIA) and immunochemiluminescent assay(ICMA) in the abscence of plasma sulfonylureas (or drug causing hypoglycemia)
  • Insulin level >6uU/mL(43p mol/L by RIA and ≥3uU/ml by ICMA
  • Glucose level <2.5mmol/L(45 mg/dL)
  • C-peptide level ≥200 pmol/L
    • Pronsulin level ≥25% or ≥22pmol/L is included in some criteria also
• The gold standard for diagnosis classically had been 72 hour fasting test
  • 33% patients develop symptoms in 12 hours, 80% at 24 hours, 90% after 48 hours and 100% after 72 hours of fasting.

<Algorithm used commonly in the past>

Suspicion of Insulinoma

Whipple's triad confirmed

72 hour fast

Positive

Negative

MRI/CT

Prolonged OGTT or mixed meal

No visible lesion

Visible lesion(s)

Unresectable liver metastasis

Nohypoglycemia

Hypoglycemia

F01

F02

F03