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HYPOGLICEMIA <ul><li>“ NORMAL” PLASMA GLUCOSE LEVELS: 60-100 mgdl </li></ul><ul><li>“ NORMAL VALUES “ DEPEND ON: </li></ul...
HYPOGLICEMIA <ul><li>GLUCOSE CONTROL: INTERACTIONS BETWEEN </li></ul><ul><ul><li>INSULIN LEVELS </li></ul></ul><ul><ul><li...
HYPOGLICEMIA <ul><li>GLUCOSE CONTROL:  </li></ul><ul><ul><li>LIVER IS THE MAJOR GLYCOGEN STORAGE ( 70 gr.), AND IS DEPLETE...
HYPOGLICEMIA <ul><li>GLUCONEOGENESIS </li></ul><ul><ul><li>THIS PROCESS IS CARRIED BY: </li></ul></ul><ul><ul><li>A DECREA...
HYPOGLICEMIA <ul><li>LACK OR DEFICIENCY OF INSULIN= HYPERGLICEMIA </li></ul><ul><li>EXCESS OF INSULIN OR DEFICIENCY OF COU...
HYPOGLICEMIA <ul><li>DEFINITION: CONDITIONS IN WHICH GLUCOSE PLASMA LEVELS FALL BELOW “NORMAL” RANGES. </li></ul>www.freel...
MECHANISM TO PRODUCE HYPOGLICEMIA <ul><li>ALTERED GLUCOSE UTILIZATION </li></ul><ul><li>ALTERED GLUCOSE PRODUCTION </li></...
ETIOLOGY AND CLASIFICATION <ul><ul><li>FASTING HYPOGLICEMIA: OCCURS PRIMARILY IN THE ABSENCE  OF NUTRIENT INGESTION. </li>...
FASTING HYPOGLICEMIA <ul><li>COULD OCCUR BY ONE OR MORE OF THE FOLLOWING MECHANISM: </li></ul><ul><ul><li>EXCESS OF INSULI...
FASTING HYPOGLICEMIA <ul><li>HYPERINSULINISM </li></ul><ul><ul><li>INSULINOMA: PANCREATIC BETA CELL TUMOR.  </li></ul></ul...
INSULINOMA DIAGNOSIS <ul><li>INSULIN LEVELS > 20 U/ ml. </li></ul><ul><li>INSULIN/ GLUCOSE RATIO ( I/ G ratio) </li></ul><...
INSULINOMA TREATMENT <ul><li>SURGERY  </li></ul><ul><li>STREPTOZOTOCIN </li></ul>www.freelivedoctor.com
HYPOGLICEMIA <ul><li>NESIDIOBLASTOSIS: </li></ul><ul><ul><li>INFANTS WITH HYPERINSULINISM </li></ul></ul><ul><ul><li>WITHO...
NESIDIOBLASTOSIS <ul><li>HISTOLOGY:  </li></ul><ul><ul><li>INCREASE IN BETA CELL MASS, DERIVED FROM DUCTAL EPITHELIUM. </l...
NESIDIOBLASTOSIS <ul><li>TREATMENT: </li></ul><ul><ul><li>PARTIAL OR TOTAL PANCREATECTOMY </li></ul></ul><ul><ul><li>DIAZO...
HYPOGLICEMIA <ul><li>EXTRAPANCREATIC TUMORS </li></ul><ul><li>ECTOPIC INSULIN PRODUCTION </li></ul><ul><li>INSULIN / LIKE ...
HYPOGLICEMIA <ul><li>MESENCHIMAL TISSUE DERIVED TUMORS: </li></ul><ul><ul><li>FIBROMAS </li></ul></ul><ul><ul><li>FIBROSAR...
HYPOGLICEMIA <ul><li>SOLID TUMORS: </li></ul><ul><ul><li>HEPATOMA </li></ul></ul><ul><ul><li>ADRENAL CARCINOMAS </li></ul>...
COUNTER REGULATORY HORMONES DEFICIENCY <ul><li>GLUCAGON, EPINEPHRINE, CORTISOL, GROWTH HORMONE. </li></ul><ul><ul><li>INSU...
HYPOGLICEMIA <ul><li>LIVER DISEASES OR CONGENITAL ENZYMES DEFICIENCY </li></ul><ul><ul><li>DECRESED GLYCOGENOLISIS </li></...
HYPOGLICEMIA <ul><li>SUBSTRATES DEFICIENCIES </li></ul><ul><ul><li>ALANINE (PRIMARY AMINOACID) </li></ul></ul><ul><ul><li>...
INSULIN AUTOINMUNE HYPOGLICEMIA <ul><li>VERY RARE </li></ul><ul><li>IgG THAT BIND INSULIN IN PLASMA </li></ul><ul><li>HYPO...
POST-PANDRIAL HYPOGLICEMIA (REACTIVE)  <ul><li>ALIMENTARY TYPE: </li></ul><ul><li>G.I. SURGERY (RAPID GASTRIC EMPTYING) </...
POSTPANDRIAL HYPOGLICEMIA (REACTIVE) <ul><li>SPONTANEOUS REACTIVE HYPOGLICEMIA </li></ul><ul><ul><li>* 2 – 4 hrs. AFTER “C...
HYPOGLICEMIA <ul><li>CLINICAL PICTURE </li></ul><ul><li>NEUROGLYCOPENIC SIGNS AND SYMPTOMS </li></ul><ul><li>ADRENERGIC DI...
HYPOGLICEMIA <ul><li>THE CLINICAL PICTURE DEPENDS ON: </li></ul><ul><ul><li>RATE AND SEVERITY OF HYPOGLICEMIC INSTALLATION...
HYPOGLICEMIA <ul><li>NEUROGLYCOPENIC PICTURE: </li></ul><ul><ul><li>HEADACHE </li></ul></ul><ul><ul><li>MENTAL DULLNESS </...
HYPOGLICEMIA <ul><li>REMEMBER </li></ul><ul><li>BRAIN VULNERABILITY: BRAIN USE ONLY GLUCOSE AND KETONE BODIES AS ENERGY SO...
HYPOGLICEMIA <ul><li>ADRENERGIC DISCHARGE PICTURE: </li></ul><ul><ul><li>PALPITATIONS/ TACHYCARDIA </li></ul></ul><ul><ul>...
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Hypoglicemia

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  1. 1. HYPOGLICEMIA <ul><li>“ NORMAL” PLASMA GLUCOSE LEVELS: 60-100 mgdl </li></ul><ul><li>“ NORMAL VALUES “ DEPEND ON: </li></ul><ul><ul><li>SEX </li></ul></ul><ul><ul><li>FEED OR FASTING STATE </li></ul></ul><ul><ul><li>TIME OF FASTING </li></ul></ul>www.freelivedoctor.com
  2. 2. HYPOGLICEMIA <ul><li>GLUCOSE CONTROL: INTERACTIONS BETWEEN </li></ul><ul><ul><li>INSULIN LEVELS </li></ul></ul><ul><ul><li>COUNTERRREGULATORY HORMONES </li></ul></ul><ul><ul><li>GLUCAGON </li></ul></ul><ul><ul><li>EPINEPHRINE </li></ul></ul><ul><ul><li>CORTISOL </li></ul></ul><ul><ul><li>GROWTH HORMONE </li></ul></ul>www.freelivedoctor.com
  3. 3. HYPOGLICEMIA <ul><li>GLUCOSE CONTROL: </li></ul><ul><ul><li>LIVER IS THE MAJOR GLYCOGEN STORAGE ( 70 gr.), AND IS DEPLETED AFTER 24 hrs. OF FASTING. </li></ul></ul><ul><ul><li>TO AVOID HYPOGLICEMIA IN STARVING STATES, IT`S IMPERATIVE TO INCREASE GLUCONEOGENESIS. </li></ul></ul>www.freelivedoctor.com
  4. 4. HYPOGLICEMIA <ul><li>GLUCONEOGENESIS </li></ul><ul><ul><li>THIS PROCESS IS CARRIED BY: </li></ul></ul><ul><ul><li>A DECREASE IN INSULIN LEVELS AND INCREASE IN GLUCAGON </li></ul></ul><ul><ul><li>AN INTACT HEPATIC GLYCOGENOLYTIC AND GLUCONEOGENIC ENZYMES </li></ul></ul><ul><ul><li>MOBILIZATION OF GLUCONEOGENIC PRECURSORS ( A.A. & F.F.A.) </li></ul></ul>www.freelivedoctor.com
  5. 5. HYPOGLICEMIA <ul><li>LACK OR DEFICIENCY OF INSULIN= HYPERGLICEMIA </li></ul><ul><li>EXCESS OF INSULIN OR DEFICIENCY OF COUNTER-REGULATORY HORMONES= HYPOGLICEMIA </li></ul>www.freelivedoctor.com
  6. 6. HYPOGLICEMIA <ul><li>DEFINITION: CONDITIONS IN WHICH GLUCOSE PLASMA LEVELS FALL BELOW “NORMAL” RANGES. </li></ul>www.freelivedoctor.com
  7. 7. MECHANISM TO PRODUCE HYPOGLICEMIA <ul><li>ALTERED GLUCOSE UTILIZATION </li></ul><ul><li>ALTERED GLUCOSE PRODUCTION </li></ul><ul><li>HORMONAL CHANGES </li></ul><ul><li>ENZYMES DEFICIENCIES </li></ul><ul><li>GLUCOSE SUBSTRATE DEFICIENCIES </li></ul>www.freelivedoctor.com
  8. 8. ETIOLOGY AND CLASIFICATION <ul><ul><li>FASTING HYPOGLICEMIA: OCCURS PRIMARILY IN THE ABSENCE OF NUTRIENT INGESTION. </li></ul></ul><ul><ul><li>POST-PANDRIAL HYPOGLICEMIA: PRECIPITATED BY NUTRIENT INGESTION, ESPECIALLY “CHO” AND PROTEINS. </li></ul></ul><ul><ul><li>INDUCED HYPOGLICEMIA: INSULIN, DRUGS, ORAL HYPOGLICEMIC AGENTS, ALCOHOL, ETC. </li></ul></ul>www.freelivedoctor.com
  9. 9. FASTING HYPOGLICEMIA <ul><li>COULD OCCUR BY ONE OR MORE OF THE FOLLOWING MECHANISM: </li></ul><ul><ul><li>EXCESS OF INSULIN OR INSULIN -LIKE SUBSTANCES </li></ul></ul><ul><ul><li>DEFICIENCIES OF ANTI-INSULIN HORMONES </li></ul></ul><ul><ul><li>CONGENITAL OR ACQUIRED LIVER DISEASE </li></ul></ul><ul><ul><li>SUBSTRATE DEFICIENCY </li></ul></ul>www.freelivedoctor.com
  10. 10. FASTING HYPOGLICEMIA <ul><li>HYPERINSULINISM </li></ul><ul><ul><li>INSULINOMA: PANCREATIC BETA CELL TUMOR. </li></ul></ul><ul><ul><li>90 % ARE BENIGN </li></ul></ul><ul><ul><li>10% ARE MALIGNANT (CANCER) </li></ul></ul>www.freelivedoctor.com
  11. 11. INSULINOMA DIAGNOSIS <ul><li>INSULIN LEVELS > 20 U/ ml. </li></ul><ul><li>INSULIN/ GLUCOSE RATIO ( I/ G ratio) </li></ul><ul><li>I/G ratio > 0.4 is indicative of “relative” hyperinsulinism. </li></ul><ul><li>CT scan and or ULTRASOUND </li></ul>www.freelivedoctor.com
  12. 12. INSULINOMA TREATMENT <ul><li>SURGERY </li></ul><ul><li>STREPTOZOTOCIN </li></ul>www.freelivedoctor.com
  13. 13. HYPOGLICEMIA <ul><li>NESIDIOBLASTOSIS: </li></ul><ul><ul><li>INFANTS WITH HYPERINSULINISM </li></ul></ul><ul><ul><li>WITHOUT IDENTIFIABLE PANCREATIC NEOPLASM. </li></ul></ul>www.freelivedoctor.com
  14. 14. NESIDIOBLASTOSIS <ul><li>HISTOLOGY: </li></ul><ul><ul><li>INCREASE IN BETA CELL MASS, DERIVED FROM DUCTAL EPITHELIUM. </li></ul></ul>www.freelivedoctor.com
  15. 15. NESIDIOBLASTOSIS <ul><li>TREATMENT: </li></ul><ul><ul><li>PARTIAL OR TOTAL PANCREATECTOMY </li></ul></ul><ul><ul><li>DIAZOXIDE </li></ul></ul>www.freelivedoctor.com
  16. 16. HYPOGLICEMIA <ul><li>EXTRAPANCREATIC TUMORS </li></ul><ul><li>ECTOPIC INSULIN PRODUCTION </li></ul><ul><li>INSULIN / LIKE SYNTHESIS </li></ul><ul><li>ACELERATED GLUCOSE CONSUMPTION </li></ul><ul><li>INHIBITION OF THE LIVER TO RELEASE GLUCOSE (GLYCOGENOLISIS OR GLUCONEOGENESIS) </li></ul>www.freelivedoctor.com
  17. 17. HYPOGLICEMIA <ul><li>MESENCHIMAL TISSUE DERIVED TUMORS: </li></ul><ul><ul><li>FIBROMAS </li></ul></ul><ul><ul><li>FIBROSARCOMAS </li></ul></ul><ul><ul><li>NEUROMAS </li></ul></ul>www.freelivedoctor.com
  18. 18. HYPOGLICEMIA <ul><li>SOLID TUMORS: </li></ul><ul><ul><li>HEPATOMA </li></ul></ul><ul><ul><li>ADRENAL CARCINOMAS </li></ul></ul><ul><ul><li>G.I. CARCINOMAS </li></ul></ul>www.freelivedoctor.com
  19. 19. COUNTER REGULATORY HORMONES DEFICIENCY <ul><li>GLUCAGON, EPINEPHRINE, CORTISOL, GROWTH HORMONE. </li></ul><ul><ul><li>INSULIN IS NORMAL OR EVEN DECREASE </li></ul></ul><ul><ul><ul><li>HYPOPITUITARISM (ANY CAUSE) </li></ul></ul></ul><ul><ul><ul><li>ISOLATED DEFICIENCY OF G.H. OR A.C.T.H. </li></ul></ul></ul><ul><ul><ul><li>ADDISON`S DISEASE </li></ul></ul></ul>www.freelivedoctor.com
  20. 20. HYPOGLICEMIA <ul><li>LIVER DISEASES OR CONGENITAL ENZYMES DEFICIENCY </li></ul><ul><ul><li>DECRESED GLYCOGENOLISIS </li></ul></ul><ul><ul><li>DEPLETED GLYCOGEN STORAGE </li></ul></ul><ul><ul><li>DECREASED IN GLUCONEOGENESIS </li></ul></ul><ul><ul><li>ALTERED NEGATIVE FEED-BACK GLUCOSE-INSULIN REGULATION </li></ul></ul><ul><ul><li>*INSULIN COULD BE NORMAL OR INCREASED </li></ul></ul>www.freelivedoctor.com
  21. 21. HYPOGLICEMIA <ul><li>SUBSTRATES DEFICIENCIES </li></ul><ul><ul><li>ALANINE (PRIMARY AMINOACID) </li></ul></ul><ul><ul><li>FREE FATTY ACIDS </li></ul></ul><ul><ul><li>* IN NORMAL SUBJECTS THE RATE OF ALANINE RELEASE FROM MUSCLE DETERMINES THE RATE OF GLUCONEOGENESIS IN STARVATION STATES. </li></ul></ul>www.freelivedoctor.com
  22. 22. INSULIN AUTOINMUNE HYPOGLICEMIA <ul><li>VERY RARE </li></ul><ul><li>IgG THAT BIND INSULIN IN PLASMA </li></ul><ul><li>HYPOGLICEMIA OCCURS WHEN THERE IS A SUDDEN RELEASE OF THE INSULIN BOUNDED TO IgG. </li></ul>www.freelivedoctor.com
  23. 23. POST-PANDRIAL HYPOGLICEMIA (REACTIVE) <ul><li>ALIMENTARY TYPE: </li></ul><ul><li>G.I. SURGERY (RAPID GASTRIC EMPTYING) </li></ul><ul><li>*DUMPING SYNDROME (DIARRHEA, POOR ABSORPTION) </li></ul>www.freelivedoctor.com
  24. 24. POSTPANDRIAL HYPOGLICEMIA (REACTIVE) <ul><li>SPONTANEOUS REACTIVE HYPOGLICEMIA </li></ul><ul><ul><li>* 2 – 4 hrs. AFTER “CHO” MEAL </li></ul></ul><ul><ul><li>*GLUCOSE LEVELS < 60 mg/ dl BUT > 40 mg/dl </li></ul></ul><ul><ul><li>**THEORIES: ABNORMAL HYPERSECRETION OF INSULIN IN RESPONSE TO “ CHO” </li></ul></ul><ul><ul><li>+EARLY TYPE II D.M. </li></ul></ul><ul><ul><li>FRUCTOSE INTOLERANCE </li></ul></ul>www.freelivedoctor.com
  25. 25. HYPOGLICEMIA <ul><li>CLINICAL PICTURE </li></ul><ul><li>NEUROGLYCOPENIC SIGNS AND SYMPTOMS </li></ul><ul><li>ADRENERGIC DISCHARGE SIGNS AND SYMPTOMS </li></ul>www.freelivedoctor.com
  26. 26. HYPOGLICEMIA <ul><li>THE CLINICAL PICTURE DEPENDS ON: </li></ul><ul><ul><li>RATE AND SEVERITY OF HYPOGLICEMIC INSTALLATION </li></ul></ul><ul><ul><li>INTEGRITY OF SIMPATHETIC SYSTEM </li></ul></ul>www.freelivedoctor.com
  27. 27. HYPOGLICEMIA <ul><li>NEUROGLYCOPENIC PICTURE: </li></ul><ul><ul><li>HEADACHE </li></ul></ul><ul><ul><li>MENTAL DULLNESS </li></ul></ul><ul><ul><li>CLOUDING OF VISION </li></ul></ul><ul><ul><li>FATIGUE </li></ul></ul><ul><ul><li>CONFUSION </li></ul></ul><ul><ul><li>HALLUCINATIONS </li></ul></ul><ul><ul><li>BIZARRE BEHAVIOR </li></ul></ul><ul><ul><li>SEIZURES </li></ul></ul><ul><ul><li>COMA </li></ul></ul><ul><ul><li>IRREVERSIBLE BRAIN DAMAGE </li></ul></ul>www.freelivedoctor.com
  28. 28. HYPOGLICEMIA <ul><li>REMEMBER </li></ul><ul><li>BRAIN VULNERABILITY: BRAIN USE ONLY GLUCOSE AND KETONE BODIES AS ENERGY SOURCES. </li></ul>www.freelivedoctor.com
  29. 29. HYPOGLICEMIA <ul><li>ADRENERGIC DISCHARGE PICTURE: </li></ul><ul><ul><li>PALPITATIONS/ TACHYCARDIA </li></ul></ul><ul><ul><li>ANXIETY </li></ul></ul><ul><ul><li>SWEATING </li></ul></ul><ul><ul><li>TREMULOUSNESS </li></ul></ul><ul><ul><li>HUNGER </li></ul></ul>www.freelivedoctor.com
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