Hypoglycemia overview: Difference between revisions
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==Overview== | ==Overview== | ||
Hypoglycemia is | Hypoglycemia is a [[Pathology|pathologic]] state produced by a lower than normal level of [[glucose]] in the blood. It happens usually when blood [[glucose]] level is less than 60 or 70 mg/dL, different values (typically below 40, 50, 60, or 70 mg/dL) have been defined as low for different populations, clinical purposes, or circumstances. Patients with [[Diabetes mellitus type 1|type 1 diabetes]] may suffer an average of two episodes of symptomatic hypoglycemia per week, thousands of such episodes over a lifetime of [[Diabetes mellitus|diabetes]], and one episode of severe symptoms per year. Causes of hypoglycemia depend on age; neonatal causes are transient neonatal hypoglycemia, [[Prematurity]], [[intrauterine growth retardation]], [[perinatal asphyxia]], [[Sepsis|sepsis,]] congenital [[hypopituitarism]], beta sympathomimetic drugs[[Congenital hyperinsulinism|, congenital hyperinsulinism]], [[Infant of diabetic mother (patient information)|infant of a diabetic mother]][[Beckwith-Wiedemann syndrome|, Beckwith-Wiedemann syndrome]] and [[Inborn error of metabolism|inborn errors of carbohydrate metabolism]]. Adult hypoglycemia caused mainly by [[insulin]] or insulin secretagogue drugs, [[alcohol]], [[Hepatic failure|hepatic]], [[Renal insufficiency|renal]], or [[cardiac failure]], [[sepsis]], non-islet cell [[Pancreatic cancer|pancreatic tumors]], [[insulinoma]], and reactive hypoglycemia. The pathophysiology of hypoglycemia depends on the failure of physiological defense mechanisms and hormones such as [[insulin]], [[glucagon]], and [[epinephrine]] to correct hypoglycemia. Most of these defense mechanisms are hormones that control [[glycogenolysis]] and [[Gluconeogenesis|gluconeogenesis.]] No single value alone serves to define the hypoglycemia. So, diagnostic criteria [[Whipple's triad|(Whipple's triad]]) is needed to diagnose hypoglycemia. Complications in adults include increased the risk of [[dementia]], [[cardiovascular]] complications and maybe death. Prognosis is generally good, and 4-10% of deaths of patients with [[Diabetes mellitus type 1|type 1 diabetes]] are due to hypoglycemia. Screening of hypoglycemia should be obtained in infants who are at risk for hypoglycemia. Surveillance should be continued every three to six hours for the first 48 hours of life. Medical treatment of hypoglycemia depends on the severity of symptoms and the cause. If asymptomatic, repeating the measurement in short time and avoiding critical tasks. Twenty grams of [[glucose]] is usually sufficient to raise the blood [[glucose]] in a severe hypoglycemic and symptomatic patients. Glucose should be administered subcutaneously or intramuscularly or 25% of [[dextrose]] serum should be given intravenously. In case of postprandial hypoglycemia, the patient should have frequent small meals or snacks and foods should be high in fiber, avoiding foods high in sugar. Surgery is the best treatment for [[Insulinoma|insulinoma.]] | ||
==Historical Perspective== | ==Historical Perspective== | ||
Hypoglycemia is a Greek word that means under-sweet [[blood]]. In 1922, hypoglycemia was first discovered by James Collip when he was working on purifying [[insulin]]. He injected [[insulin]] | Hypoglycemia is a Greek word that means under-sweet [[blood]]. In 1922, hypoglycemia was first discovered by James Collip when he was working on purifying [[insulin]]. He injected <nowiki/>[[insulin]] into a rabbit and realized a reduction in [[blood glucose]] levels. Collip injected a large dose of [[insulin]] to the rabbit, that lead to [[coma]] and death of the rabbit. | ||
==Classification== | ==Classification== | ||
Hypoglycemia can be classified based on severity into 5 categories, include Severe hypoglycemia, symptomatic hypoglycemia, [[asymptomatic]] hypoglycemia, probable symptomatic hypoglycemia, and pseudo hypoglycemia. It is also can be classified based on severity into mild, moderate and severe | Hypoglycemia can be classified based on severity into 5 categories, include Severe hypoglycemia, symptomatic hypoglycemia, [[asymptomatic]] hypoglycemia, probable symptomatic hypoglycemia, and pseudo hypoglycemia. It is also can be classified based on severity into mild, moderate and severe. | ||
==Pathophysiology== | ==Pathophysiology== | ||
The pathophysiology of hypoglycemia depends on the failure of physiological defense mechanisms and hormones such as [[insulin]], [[glucagon]] and [[epinephrine]] to correct hypoglycemia. Most of these defense mechanisms are hormones that control [[glycogenolysis]] and [[Gluconeogenesis|gluconeogenesis.]] | The pathophysiology of hypoglycemia depends on the failure of physiological defense mechanisms and hormones such as [[insulin]], [[glucagon]], and [[epinephrine]] to correct hypoglycemia. Most of these defense mechanisms are hormones that control [[glycogenolysis]] and [[Gluconeogenesis|gluconeogenesis.]] | ||
Causes of hypoglycemia depend on age; neonatal causes are transient neonatal hypoglycemia, [[Prematurity]], [[intrauterine growth retardation]], [[perinatal asphyxia]], [[Sepsis|sepsis,]] congenital [[hypopituitarism]], beta sympathomimetic drugs[[Congenital hyperinsulinism|, congenital hyperinsulinism]], [[Infant of diabetic mother (patient information)|infant of a diabetic mother]][[Beckwith-Wiedemann syndrome|, Beckwith-Wiedemann syndrome]] and [[Inborn error of metabolism|inborn errors of carbohydrate metabolism]]. Causes of adult hypoglycemia are | Causes of hypoglycemia depend on age; neonatal causes are transient neonatal hypoglycemia, [[Prematurity]], [[intrauterine growth retardation]], [[perinatal asphyxia]], [[Sepsis|sepsis,]] congenital [[hypopituitarism]], beta sympathomimetic drugs[[Congenital hyperinsulinism|, congenital hyperinsulinism]], [[Infant of diabetic mother (patient information)|infant of a diabetic mother]][[Beckwith-Wiedemann syndrome|, Beckwith-Wiedemann syndrome]] and [[Inborn error of metabolism|inborn errors of carbohydrate metabolism]]. Causes of adult hypoglycemia are [[insulin]] or insulin secretagogue drugs, [[alcohol]], [[Hepatic failure|hepatic]], [[Renal insufficiency|renal]], or [[cardiac failure]], [[sepsis]], non-islet cell [[Pancreatic cancer|pancreatic tumors]], [[insulinoma]], reactive hypoglycemia, post [[Gastric bypass surgery|gastric bypass]] hypoglycemia, [[Autoimmune|autoimmun]]<nowiki/>e hypoglycemia. | ||
==Differentiating Hypoglycemia from other Diseases== | ==Differentiating Hypoglycemia from other Diseases== | ||
Hypoglycemia should be differentiated from other causes of [[autonomic]] hyperactivity symptoms. Physicians should have history, signs and laboratory results sufficient to help them to identify the cause of hypoglycemia. Neonatal hypoglycemia should be differentiated from other causes of neurological symptoms in neonates such as [[sepsis]], metabolic diseases: [[urea cycle disorders]], and branched-chain organic acidemias, [[hyponatremia]] and [[Asphyxia|neonatal asphyxia]]. | Hypoglycemia should be differentiated from other causes of [[autonomic]] hyperactivity symptoms. Physicians should have history, signs and laboratory results sufficient to help them to identify the cause of hypoglycemia. Neonatal hypoglycemia should be differentiated from other causes of neurological symptoms in neonates such as [[sepsis]], metabolic diseases: [[urea cycle disorders]], and [[Branched-chain amino acids|branched-chain]] [[Organic acidemia|organic acidemias]], [[hyponatremia]] and [[Asphyxia|neonatal asphyxia]]. | ||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
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==Risk Factors== | ==Risk Factors== | ||
Risk factors of hypoglycemia include [[Diabetes mellitus|diabetic]] patients with excessive insulin doses especially after missed meals or after exercise, nocturnal or with [[alcohol]]. Absolute endogenous [[insulin]] | Risk factors of hypoglycemia include [[Diabetes mellitus|diabetic]] patients with excessive insulin doses especially after missed meals or after exercise, nocturnal or with [[alcohol]]. Absolute endogenous <nowiki/>[[insulin]] deficiency is another risk factor. | ||
== Screening == | == Screening == | ||
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==Natural History, Complications and Prognosis== | ==Natural History, Complications and Prognosis== | ||
If left untreated, patients with hypoglycemia may progress to develop [[anxiety]], [[nervousness]], [[tremor]], [[Palpitation|palpitations,]] and sweating. Common complications of hypoglycemia include [[psychomotor retardation]], [[epilepsy]] and [[prematurity]] in neonates. Complications in adults include increased the risk of [[dementia]], [[cardiovascular]] complications and | If left untreated, patients with hypoglycemia may progress to develop [[anxiety]], [[nervousness]], [[tremor]], [[Palpitation|palpitations,]] and sweating. Common complications of hypoglycemia include [[psychomotor retardation]], [[epilepsy|epilepsy,]] and [[prematurity]] in neonates. Complications in adults include increased the risk of [[dementia]], [[cardiovascular]] complications and maybe death. Prognosis is generally good, and 4-10% of deaths of patients with [[Diabetes mellitus type 1|type 1 diabetes]] are due to hypoglycemia. | ||
==Diagnosis== | ==Diagnosis== | ||
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On EKG, hypoglycemia is characterized by [[sinus tachycardia]] and [[supraventricular tachycardia]]. | On EKG, hypoglycemia is characterized by [[sinus tachycardia]] and [[supraventricular tachycardia]]. | ||
===Chest X Ray=== | ===Chest X-Ray=== | ||
There | There are no x-ray findings in hypoglycemia. | ||
===CT=== | ===CT=== | ||
[[Ultrasound]], [[Computed tomography]] and [[Magnetic resonance imaging|MRI]] can differentiate between [[insulinoma]] and islet-cell [[hypertrophy]]. | [[Ultrasound]], [[Computed tomography]], and [[Magnetic resonance imaging|MRI]] can differentiate between [[insulinoma]] and islet-cell [[hypertrophy]]. | ||
===MRI=== | ===MRI=== | ||
[[Magnetic resonance imaging|MRI]] scan is helpful in the diagnosis of [[insulinoma]] in the case of failed [[Computed tomography|CT.]] | [[Magnetic resonance imaging|MRI]] scan is helpful in the diagnosis of [[insulinoma]] in the case of failed [[Computed tomography|CT.]] | ||
===Echocardiography or Ultrasound=== | ===Echocardiography or Ultrasound=== | ||
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===Medical Therapy=== | ===Medical Therapy=== | ||
Medical treatment of hypoglycemia depends on the severity of symptoms and the cause. If asymptomatic, repeating the measurement in short time and avoiding critical tasks. Twenty grams of gucose | Medical treatment of hypoglycemia depends on the severity of symptoms and the cause. If asymptomatic, repeating the measurement in short time and avoiding critical tasks. Twenty grams of gucose are usually sufficient to raise the blood glucose in a severe hypoglycemic and symptomatic patients. Glucose should be administered subcutaneously or intramuscularly or 25% of [[dextrose]] serum should be given intravenously. In case of postprandial hypoglycemia. The patient should have frequent small meals or snacks and foods should be high in fiber, avoiding foods high in sugar. Surgery is the best treatment for [[Insulinoma|insulinoma.]] | ||
===Surgery=== | ===Surgery=== | ||
Revision as of 13:58, 22 September 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]
Overview
Hypoglycemia is a pathologic state produced by a lower than normal level of glucose in the blood. It happens usually when blood glucose level is less than 60 or 70 mg/dL, different values (typically below 40, 50, 60, or 70 mg/dL) have been defined as low for different populations, clinical purposes, or circumstances. Patients with type 1 diabetes may suffer an average of two episodes of symptomatic hypoglycemia per week, thousands of such episodes over a lifetime of diabetes, and one episode of severe symptoms per year. Causes of hypoglycemia depend on age; neonatal causes are transient neonatal hypoglycemia, Prematurity, intrauterine growth retardation, perinatal asphyxia, sepsis, congenital hypopituitarism, beta sympathomimetic drugs, congenital hyperinsulinism, infant of a diabetic mother, Beckwith-Wiedemann syndrome and inborn errors of carbohydrate metabolism. Adult hypoglycemia caused mainly by insulin or insulin secretagogue drugs, alcohol, hepatic, renal, or cardiac failure, sepsis, non-islet cell pancreatic tumors, insulinoma, and reactive hypoglycemia. The pathophysiology of hypoglycemia depends on the failure of physiological defense mechanisms and hormones such as insulin, glucagon, and epinephrine to correct hypoglycemia. Most of these defense mechanisms are hormones that control glycogenolysis and gluconeogenesis. No single value alone serves to define the hypoglycemia. So, diagnostic criteria (Whipple's triad) is needed to diagnose hypoglycemia. Complications in adults include increased the risk of dementia, cardiovascular complications and maybe death. Prognosis is generally good, and 4-10% of deaths of patients with type 1 diabetes are due to hypoglycemia. Screening of hypoglycemia should be obtained in infants who are at risk for hypoglycemia. Surveillance should be continued every three to six hours for the first 48 hours of life. Medical treatment of hypoglycemia depends on the severity of symptoms and the cause. If asymptomatic, repeating the measurement in short time and avoiding critical tasks. Twenty grams of glucose is usually sufficient to raise the blood glucose in a severe hypoglycemic and symptomatic patients. Glucose should be administered subcutaneously or intramuscularly or 25% of dextrose serum should be given intravenously. In case of postprandial hypoglycemia, the patient should have frequent small meals or snacks and foods should be high in fiber, avoiding foods high in sugar. Surgery is the best treatment for insulinoma.
Historical Perspective
Hypoglycemia is a Greek word that means under-sweet blood. In 1922, hypoglycemia was first discovered by James Collip when he was working on purifying insulin. He injected insulin into a rabbit and realized a reduction in blood glucose levels. Collip injected a large dose of insulin to the rabbit, that lead to coma and death of the rabbit.
Classification
Hypoglycemia can be classified based on severity into 5 categories, include Severe hypoglycemia, symptomatic hypoglycemia, asymptomatic hypoglycemia, probable symptomatic hypoglycemia, and pseudo hypoglycemia. It is also can be classified based on severity into mild, moderate and severe.
Pathophysiology
The pathophysiology of hypoglycemia depends on the failure of physiological defense mechanisms and hormones such as insulin, glucagon, and epinephrine to correct hypoglycemia. Most of these defense mechanisms are hormones that control glycogenolysis and gluconeogenesis.
Causes of hypoglycemia depend on age; neonatal causes are transient neonatal hypoglycemia, Prematurity, intrauterine growth retardation, perinatal asphyxia, sepsis, congenital hypopituitarism, beta sympathomimetic drugs, congenital hyperinsulinism, infant of a diabetic mother, Beckwith-Wiedemann syndrome and inborn errors of carbohydrate metabolism. Causes of adult hypoglycemia are insulin or insulin secretagogue drugs, alcohol, hepatic, renal, or cardiac failure, sepsis, non-islet cell pancreatic tumors, insulinoma, reactive hypoglycemia, post gastric bypass hypoglycemia, autoimmune hypoglycemia.
Differentiating Hypoglycemia from other Diseases
Hypoglycemia should be differentiated from other causes of autonomic hyperactivity symptoms. Physicians should have history, signs and laboratory results sufficient to help them to identify the cause of hypoglycemia. Neonatal hypoglycemia should be differentiated from other causes of neurological symptoms in neonates such as sepsis, metabolic diseases: urea cycle disorders, and branched-chain organic acidemias, hyponatremia and neonatal asphyxia.
Epidemiology and Demographics
Patients with type 1 diabetes may suffer an average of two episodes of symptomatic hypoglycemia per week, thousands of such episodes over a lifetime of diabetes, and one episode of severe symptoms per year. Hypoglycemia is less frequent in type 2 diabetes than it is in type1. Event rate for severe hypoglycemia range from 40 to 100 percent of those in type 1 diabetes. There is no racial or gender predilection of hypoglycemia.
Risk Factors
Risk factors of hypoglycemia include diabetic patients with excessive insulin doses especially after missed meals or after exercise, nocturnal or with alcohol. Absolute endogenous insulin deficiency is another risk factor.
Screening
Screening of hypoglycemia should be obtained in infants who are at risk for hypoglycemia. Surveillance should be continued every three to six hours for the first 48 hours of life. Treatment should be started immediately after primary blood test and we should not wait for the confirmatory laboratory results due to high risk of the neurological outcome.
Natural History, Complications and Prognosis
If left untreated, patients with hypoglycemia may progress to develop anxiety, nervousness, tremor, palpitations, and sweating. Common complications of hypoglycemia include psychomotor retardation, epilepsy, and prematurity in neonates. Complications in adults include increased the risk of dementia, cardiovascular complications and maybe death. Prognosis is generally good, and 4-10% of deaths of patients with type 1 diabetes are due to hypoglycemia.
Diagnosis
Diagnostic criteria
Diagnostic criteria of hypoglycemia include symptoms of hypoglycemia, a low plasma glucose concentration correlated with symptoms, and correction of glucose level relieves symptoms. These criteria called Whipple's triad. Neonatal hypoglycemia can be diagnosed by measuring multiple metabolic panels include plasma insulin, plasma C-peptide, beta-hydroxybutyrate, blood pH, bicarbonate, lactate, free fatty acids, acylcarnitine profile, plasma free and total carnitine levels.
History and Symptoms
Hypoglycemic symptoms and manifestations can be divided into those produced by the counter-regulatory hormones: adrenergic Manifestations: anxiety, nervousness, tremor, Palpitations, Sweating, coldness. Glucagon Manifestations: Hunger, nausea, vomiting. Neuroglycopenic Manifestations: irritability, weakness, apathy, lethargy Confusion, amnesia.
Physical Examination
Main signs of hypoglycemia are tachycardia and ventricular arrhythmia. Neurological manifestations include altered mental status, hypotonia, focal or general motor deficit and jerks. Neonatal hypoglycemia signs include large for gestational age, hepatomegaly in Beckwith-Wiedemann syndrome and glycogen storage diseases. Ambiguous genitalia, hypertension, hyponatremia, and hyperkalemia are found in congenital adrenal insufficiency.
Laboratory Findings
Laboratory investigations of hypoglycemia depend on many tests: plasma glucose should be <55 mg/dL, insulin, c-peptide, proinsulin, sulfonylurea screen, beta-hydroxybutyrate, 24-hour fasting glucose level and identifying the cause after that.
Electrocardiogram
On EKG, hypoglycemia is characterized by sinus tachycardia and supraventricular tachycardia.
Chest X-Ray
There are no x-ray findings in hypoglycemia.
CT
Ultrasound, Computed tomography, and MRI can differentiate between insulinoma and islet-cell hypertrophy.
MRI
MRI scan is helpful in the diagnosis of insulinoma in the case of failed CT.
Echocardiography or Ultrasound
Other Imaging Findings
There are no other imaging findings associated with hypoglycemia.
Other Diagnostic Studies
Other tests include: injection of calcium gluconate into splanchnic arteries and venous sampling searching for insulin.
Treatment
Medical Therapy
Medical treatment of hypoglycemia depends on the severity of symptoms and the cause. If asymptomatic, repeating the measurement in short time and avoiding critical tasks. Twenty grams of gucose are usually sufficient to raise the blood glucose in a severe hypoglycemic and symptomatic patients. Glucose should be administered subcutaneously or intramuscularly or 25% of dextrose serum should be given intravenously. In case of postprandial hypoglycemia. The patient should have frequent small meals or snacks and foods should be high in fiber, avoiding foods high in sugar. Surgery is the best treatment for insulinoma.
Surgery
Surgical removal of the insulinoma is the treatment of choice and resection of metastatic liver disease.
Primary Prevention
The main issue is patient education about nature, symptoms, how to measure glucose level and how to treat. Reactive hypoglycemia prevention depends on changing eating patterns smaller meals and avoiding excessive sugar.
Secondary Prevention
Secondary Prevention is the same as primary prevention.