Whipple's Triad

[Aclamity]

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How is Whipple's Triad specific for an insulinoma?? Seems like anyone who's just "not eating enough" would be able to satisfy it. I normally wouldn't care, but

SPOILER ALERT FROM FREE 150

There was one question from free 150 where I think they were trying to get at insulinoma, but the C-peptide and insulin levels were normal (insulin was at the high end of normal, but still normal). It sounded like the only thing that would lead you to say insulinoma was that it satisfied Whipple's. Are insulin/C-peptide levels not that high in insulinoma?

 

[illegallysmooth]

How is Whipple's Triad specific for an insulinoma?? Seems like anyone who's just "not eating enough" would be able to satisfy it. I normally wouldn't care, but

SPOILER ALERT FROM FREE 150

There was one question from free 150 where I think they were trying to get at insulinoma, but the C-peptide and insulin levels were normal (insulin was at the high end of normal, but still normal). It sounded like the only thing that would lead you to say insulinoma was that it satisfied Whipple's. Are insulin/C-peptide levels not that high in insulinoma?

could it have possibly been a disorder of fatty acid metabolism (e.g. MCAD def)? Or a glycogen storage disease?

 

[johndoe3344]

How is Whipple's Triad specific for an insulinoma?? Seems like anyone who's just "not eating enough" would be able to satisfy it. I normally wouldn't care, but

SPOILER ALERT FROM FREE 150

There was one question from free 150 where I think they were trying to get at insulinoma, but the C-peptide and insulin levels were normal (insulin was at the high end of normal, but still normal). It sounded like the only thing that would lead you to say insulinoma was that it satisfied Whipple's. Are insulin/C-peptide levels not that high in insulinoma?

C-peptide is high in any type of exaggerated endogenous insulin production, including insulinoma.

 

[Aclamity]

could it have possibly been a disorder of fatty acid metabolism (e.g. MCAD def)? Or a glycogen storage disease?

Well the question pretty much had a hypoglycemic patient who got better after eating. Blood tests showed low glucose, normal cortisol, C-peptide on the low end of normal, insulin on the high end of normal, no detection of sulfonylurea.

While reading through the stem + lab values, everything was screaming "insulin OD" at me, but then the question asked "where is the most likely location of her TUMOR?" The answer was pancreas (so I can only assume insulinoma, though I may be wrong).

If C-peptide and insulin levels had been sky-high I would've chosen insulinoma, but alas! they weren't. So now I'm confused as to (a) what the real answer is, and (b) if insulinoma, wtf is up with the lab values?

 

[Go Ducks]

I really suck at endo so this could be off base, but if I saw hypoglycemia with normal insulin then I'd think low glucagon, which could be from a somatostatin producing tumor of delta cells. This would fit the answer of "tumor in the pancreas." Even then, doesn't really fit well with insulin being at the high end of normal.

 

[Aclamity]

I really suck at endo so this could be off base, but if I saw hypoglycemia with normal insulin then I'd think low glucagon, which could be from a somatostatin producing tumor of delta cells. This would fit the answer of "tumor in the pancreas." Even then, doesn't really fit well with insulin being at the high end of normal.

woah. I don't know what it was about your post, but it totally made me think of something... with really low glucose you would expect the insulin level to be almost zero (negative feedback), so an insulin level at the high end of normal is actually "inappropriately normal." So I guess it really does follow along with an insulinoma

Your idea about somatostatinoma is a valid one, though. However I think the patient would also present with lots of other symptoms (steatorrhea, gallstones, etc.)

 

[Phloston]

LOL. I'm actually posting blindly here. When I saw your "spoiler alert from free 150," I was like, "there's no way I could read this!!"

 

[Go Ducks]

woah. I don't know what it was about your post, but it totally made me think of something... with really low glucose you would expect the insulin level to be almost zero (negative feedback), so an insulin level at the high end of normal is actually "inappropriately normal." So I guess it really does follow along with an insulinoma

Your idea about somatostatinoma is a valid one, though. However I think the patient would also present with lots of other symptoms (steatorrhea, gallstones, etc.)

I like your answer! I think you're right.

Note, however, that often times not all of a patient's symptoms will be given to you in a question. 🙁

EDIT: I like your answer less as I think about it more. An insulinoma would be secreting level, elevated amounts of insulin and not responsive to negative feedback anyway, so the amount they are secreting when the glucose is very low would be the amount they were secreting when the glucose was normal. Therefore their normal glucose level still does not compute.

 

[acciddropping]

Whipple Triad is suggestive of, but not specific for an insulinoma.