Download MBBS Medicine Hypoglycemia Lecture PPT

HYPOGLYCEMIA

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Reduction of plasma glucose to a level that
induces symptoms and signs
Altered mental status

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Sympathetic nervous stimulation
Usual y < 50 mg/dl
Highly variable
Abnormalities of mechanisms of glucose
homeostasis

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Whipples triad
Documentation of low blood sugar
Presence of symptoms
Reversal of symptoms with restoration of
blood sugar values

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Pathophysiology
Symptoms
Sympathetic activation and brain dysfunction
secondary to decreased blood glucose
Sympathoadrenal

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Sweating /palpitations/anxiety/hunger
Neuroglycopenia
Confusion/difficulty in concentration/
irritability/focal impairments/ hal ucinations/coma/
death

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Pathophysiology
Adrenergic symptoms precede neuro
glycopenia
Primary stimulus for release of
catacholamines is absolute level of glucose

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Previous blood sugar levels can influence
Hypoglycemia unawareness
Repeated episodes can blunt symptoms

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Etiology
Medication change / overdose

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Infection
Diet change
Metabolic changes
Fasting
Insulin producing tumors

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Hepatic disease

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Fasting hypoglycemia
Causes
Inherited ? enzyme deficiencies that restrict
hepatic glucose release

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Inherited defects in fatty acid oxidation-
restrict the extent to which non neural tissues
can derive their energy from FFA
Nesidioblastosis- budding of insulin secreting
cel s from the pancreatic duct

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Drugs ? ethanol/ OHA/ insulin/ INH/
fluoxetine/ SSRI/ ACE inhibitors/ lithium/
tramadol
Sulphonyl urea overuse/ abuse
Exogenous insulin

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Endogenous insulin- insulinomas/ non beta
cel tumors

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Reactive hypoglycemia
Idiopathic
Alimentary ? GI procedures- rapid entry and

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absorption of glucose into the intestine-
excessive insulin response to a meal
Congenital enzyme deficiencies - fructose
intolerance/ galactosemia

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Other causes

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Auto immune ? insulin and insulin receptor
antibodies
Hormonal deficiencies- hypoadrenalism
hypopitutarism
Critical il ness- hepatic/ renal/ cardiac/ MODS

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Exercise
Pregnancy
Renal glycosuria
Ketosis
starvation

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Clinical presentation
History
Neuro glycopenic
Adrenergic
Fasting- usual y in the morning before food

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Reactive- more common in obese patients/
insulin resistance/ rarely loss of
consciousness, no severe neuro glycopenia

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Clinical presentation
Blurred vision/ pupils constricted or dilated or

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not reacting
Hypotension/ hypotension/arrhythmias
Coma/ confusion/ fatigue/ diplopia/ agitation/
strokes/ tumors/ convulsions
Dyspnoea/ tachypnoea/ acute pulmonary

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edema
Dehydration
Atypical in elderly and the very young

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Differentials
Hepatic failure

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TIA
Cardiac dysrhythmias
Endocrine disorders
Substance abuse- ethanol/ cocaine
Hypoglycemic agents

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CNS disorders
Psychogenic

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Work up
Look for
Infection

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DKA
Cardiac and neurologic causes
Glucose and insulin levels
Simultaneously
72 hour fasting

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C peptide levels increased with insulinoma and
sulphonyl ureas/ low or normal with exogenous
insulin

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Imaging
Usg

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CT
MRI

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Treatment
GLUCOSE / GLUCOSE/ GLUCOSE
Underlying causes

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Complications
Acute sequelae
Coma/ cardiac arrest/ death
Permanent deficits increase with
Prolonged hypoglycemia- hemi paresis/

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memory impairment/ apraxia/ ataxia/
diminished language skil s

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Medication
Dextrose
Glucose elevating agents

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Glucagon- inhibits glycogen synthesis/
enhances non carbohydrate glucose
formation
Insulin secretion inhibitors ? diazoxide- direct
inhibitor/ octreotide- somatostatin receptor

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Anti neoplastic agents- streptozocin ? tumor
inhibitor

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Hypoglycemia Patient
Questionnaire
How wel can you recognize symptoms

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How often do you have symptoms
Have you needed assistance
Do you check your glucose before driving
Do your relatives know what to do

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THANK YOU

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