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62 Cards in this Set

  • Front
  • Back
Insulinoma
-what is it
-functional neoplasm originating from the pancreatic beta-cell in the islet of Langerhans
Insulinoma
-effect on insulin levels
-autonomously secretes excessive amounts of insulin (hyperinsulinemia)
-non-responsive to serum glucose fluctuations
Insulinoma
-signalment
-common in ferrets

-uncommon in dogs (middle aged and older, medium to large breed)

-rare in cats
Insulinoma
-severity in dogs
-malignant
-usually metastasized by time of diagnosis
-metastasize to lymph nodes, liver, lungs
Insulinoma
-principle metabolic abnormality
-hypoglycemia (excessive insulin)
Insulinoma
-therapy
-supportive to correct hypoglycemia
-anti-tumor (surgery, chemo)
Insulinoma
-etiology
-unknown
Insulinoma
-requirement for definitive diagnosis
-histiologic examination of tissue samples
Insulinoma
-differential diagnoses
Disorders that cause hypoglycemia
-glycogen storage disorders
-puppy hypoglycemia
-hunting dog hypoglycemia
-hypoadrenocorticism
-paraneoplastic hypoglycemia
-hypopituitarism
-metabolic immaturity
-sepatic disorders (PSS, liver failure, etc.)
-Sepsis
-prolonged fasting/malnutrition
-pregnancy
-drugs/toxins
Hypoglycemia
-can be due to
-production of insulin/insulin-like substance
-decreased glucose production
-inc. glucose consumption
To differentiate insulinoma from other causes of hypoglycemia, what is important to do?
Interpret in the context of all available patient information
-signalment
-history
-physical exam
-minimal lab data base
Hypoglycemia
-severity and type of clinical signs related to:
-rate of glucose decline
-absolute blood glucose conc.
-duration of hypoglycemia
Hypoglycemia
-signs
Adrenergic signs
-restlessness
-PU/PD
-diarrhea
-anorexia
-focal or diffuse muscle fasiculations

Neuroglycopenic signs
-hunger
-fatigue
-ataxia
-blindness
-weakness
-collapse
-seizure
-coma
Adrenergic signs of hypoglycemia
-due to
counter-regulatory response
-glucagon
-epinephrine
-cortisol
Hypoglycemia
-why do the neurological signs occur
-the brain relies primarily on glucose for energy
Insulinoma
-History/Clinical signs
-Signs of hypoglycemia

Episodic/Intermittent signs
-last seconds to minutes
-compensatory counterregulatory mechanisms

Weight gain
Insulinoma
-when may signs occur
-during a fast
-several hrs after a meal
-after exercise
-excitement
-stressful event
Insulinoma
-ways to diagnose
-routine lab chemistry
-Whipples's Triad
-Imaging
-Histopathology
Insulinoma
-diagnosis with routine lab assessment
-CBC and serum chem normal except for glucose
-fasting blood glucose well below normal
-rule out artifact hypoglycemia (RBCs consuming glucose)
How to prevent artifact hypoglycemia
-store blood in a grey top tube (Paralyze RBC metabolism)
Whipple's triad
-neurological signs present
-signs present when hypoglycemia is present
-signs improve with the administration of dextrose
Insulinoma
-why are radiographs not helpful?
-tumors are typically very small and do not cause a mass effect
Insulinoma
-why is histopathology usually not to helpful in diagnosis?
-usually done either after surgery or at necropsy
Insulinoma
-definitive diagnosis depends on
-insulin level being relatively high relative to the fasting glucose concentration
Insulinoma
-methods of treatment
-surgical
-medical management of hypoglycemia
-chemotherapy
Insulinoma
-treatment of choice
-surgery
Insulinoma
-surgery goal
-remove primary adenoma and any metastasis
Insulinoma
-how to increase survival time
-follow debulking with medical management
Insulinoma
-Surgery Immediate complications
-intraoperative hypoglycemia (lead to brain injury if not monitored)
-post-operative pancreatitis, DKA, sepsis

-12% post-op mortality
Insulinoma
-Surgery late complications
-diabetes mellitus (pancreas removal)
-recurrent hypoglycemia (most common due to the tumor returning)
-Exocrine insufficiency
Insulinoma
-emergency therapy for hypoglycemia
-Corn syrup (oral mm)
-IV dextrose bolus
-IV glucagon CRI
Insulinoma
-problem with administration of IV dextrose bolus
-rebound hypoglycemia can occur with stimulation of the insulinoma
Insulinoma
-IV glucagon CRI function
-facilitate glucose produced by the liver
-possible insulin inhibition
Insulinoma
-chronic medical management
-glucocorticoids
-diet
-environment
Insulinoma
-primary medical therapy in dogs
-glucocorticoids
Insulinoma
-goal for glucocorticoid treatment
-antagonize the effects of insulin
-induce insulin resistance in target tissues

also enhances hepatic gluconeogenesis and glycogenolysis
Insulinoma
-goal for treatment via altered diet
-minimize rapid increase in blood glucose concentration
Insulinoma
-diet changes for management
-frequent feedings
-high fat, protein, complex carbs
-limited simple sugars
Insulinoma
-environment changes for treatment
-minimize exposure to stress/excitatory events
-limit exercise
Infrequently used drugs for hypoglycemia
-why
-Diazoxide
-Octreotide



-expensive
Diazoxide
-function
-inhibits insulin release at the cellular level
Octreotide
-function
-direct inhibition of insulin release by binding to somatostatin receptors
Most dogs receiving medical management for insulinoma are managed how?
-diet
-prednisone
Insulinoma
-chemotherapy agent
-Streptozotocin
Streptozotocin
-function
-direct toxic effects on pancreatic beta cells
Streptozotocin
-side effects
-nephrotoxic
-inc. liver enzymes
-thrombocytopenia
-renal failure


-relapse usually occurs
Insulinoma
-prognosis
Short term---> good

Median survival times
-Medical therapy alone (shorter)
-metastatic dz (middle)
-all visible disease removed (longest)

Obvious metastatic disease ---> poor long term
Puppy hypoglycemia
-signalment
-toy/miniature breeds
- <6 mo
Puppy hypoglycemia
-possible causes
-high energy requirements
-inadequate protein reserves for glucose production
-poorly developed gluconeogenic enzymes

-precipitated by other illnesses
Puppy hypoglycemia
-R/Os
-PSS
-sepsis
-genetics (glycogen storage dz)
Puppy hypoglycemia
-diagnosis
-signalment
-clinical signs
-hypoglycemia
Puppy hypoglycemia
-treatment
Acute
-IV dextrose supplement

Chronic
-frequent feeding
-L-carnitine
Hunting dog hypoglycemia
-history
-hunting dog during strenuous exercise
Hunting dog hypoglycemia
-possible cause
-muscle/hepatic glycogen depletion
Hunting dog hypoglycemia
-diagnosis
-signalment
-history
-BG
Hunting dog hypoglycemia
-treatment
-owner education
-altered feeding schedule
-change in training/hunting activity
Glycogen storage disease
-signalment
-young dogs and cats
-GSP, Maltese
-Norwegian forest cat
Glycogen Storage Disease
-cause
-genetic mutation prevents normal glycogenolysis
Glycogen storage disease
-clinical signs
-failure to thrive
-hepatomegaly
-hypoglycemia
Glycogen storage disease
-diagnosis
-liver biopsy
-genetic analysis
Paraneoplastic hypoglycemia
-mechanisms
-deranged glucose metabolism in neoplastic cells
-inc. glucose use by large tumors
-tumor secretion of insulin-like factor
-decreased hepatic function
Paraneoplastic hypoglycemia
-treatment
-correct hypoglycemia
-therapy for neoplasia