Recurrent Hypoglycemia: Endoscopic Ultrasound to the Rescue

Case Report

Austin J Gastroenterol. 2023; 10(1): 1123.

Recurrent Hypoglycemia: Endoscopic Ultrasound to the Rescue

Anikhindi SA¹*; Anikhindi AA¹; Bakshi P²; Badwal S²; Belho E³; Mehta N4; Kumar A¹; Arora A¹

1Department of Gastroenterology, Sir Ganga Ram hospital, New Delhi, India

2Department of Pathology, Sir Ganga Ram hospital, New Delhi, India

3Department of Nuclear Medicine, Sir Ganga Ram hospital, New Delhi, India

4Department of Surgical Gastroenterology, Sir Ganga Ram hospital, New Delhi, India

*Corresponding author: Anikhindi SA Consultant, Department of Gastroenterology, Sir Ganga Ram hospital Tel: +91- 8373956846 Email: dr.anikhindi@gmail.com

Received: July 25, 2023 Accepted: September 06, 2023 Published: September 13, 2023

Abstract

Insulinoma is a rare pancreatic neuroendocrine tumor with an incidence of 4 per million. Ectopic insulinomas are even rarer and comprise 1-2% of these cases. In cases which have established endogenous hyperinsulinemic hypoglycemia, a high-index of suspicion must be maintained since conventional tests like Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) may miss these tumors. Endoscopic ultrasound can be utilised in localisation as it is more sensitive and specific compared to CT or MRI with an added applicability in obtaining a biopsy. However, operator skill and experience play a crucial role in identifying extra-pancreatic insulinomas.

Keywords: Insulinoma; Endoscopic ultrasound; Neuroendocrine tumor; Hypoglycemia

Introduction

Pancreatic neuroendocrine neoplasms account for 2-3% of all pancreatic tumors [1]. Insulinoma is the most common pancreatic neuroendocrine tumor [2-3] with an incidence of 4 per million patients per year [4]. Almost 90% cases are benign in nature and 90% are intra-pancreatic in origin [5-8]. Extra-pancreatic insulinomas are very rare and comprises about 1-2% of all insulinomas [9]. Most of these tumors present with Whipple’s triad clinically along with Endogenous Hyperinsulinemic Hypoglycemia (EHH) [10-11].

Diagnosing an insulinoma is often challenging and requires a high index of suspicion and careful assessment. In cases where conventional non-invasive imaging like CT and MRI may often fail to localise these tumors, an endoscopic ultrasound plays often comes to the rescue.

There are very few case reports of extra-pancreatic insulinoma which have been published globally. Here, we present a case of an extra-pancreatic insulinoma localised by endoscopic ultrasound to the pancreatico-duodenal groove.

Case Description

A 44-year-old female presented to the out-patient department with recurrent episodes of dizziness, sweating, palpitations and dryness of mouth over the last 4 months. The episodes were triggered by physical activity and relieved with meals. Patient always kept a snack in her bag to prevent such episodes. There was no history of weight gain. Patient had no history of diabetes mellitus; sulfonylurea screen was negative. On the basis of history and lab investigation (Table 1) which showed low glucose (65 md/dl), Endogenous Hyperinsulinemic Hypoglycemia (EHH) was suspected. Previous multiple abdominal imaging studies including a Contrast Enhanced Magnetic Resonance (CEMR) of abdomen were normal.