Insulinoma is a tumor of the pancreas (pancreas) that grows from beta cells, islets of Langerhans. By nature, it refers to endocrine formations, that is, is hormone-active. It differs in that it produces insulin in an increased uncontrolled amount, causing hyperinsulinism and, as a result, hypoglycemia.
All the symptoms and its name are associated with this. Usually it is solid, single, but in 105 cases it can be multiple. Her hormonal activity is autonomous. In 85-90% of cases, it is benign, and only in 10-15% it is malignant. It can develop at any age, even in infants, but this is rare. More common after 45 years, in women 4 times more often.
Insulinoma can grow in any part of the pancreas, but more often in its caudal part. In 1% of cases, the location is ectopic or extrapancreatic - the gate of the spleen, stomach wall or duodenum, in the liver.
Typically, the size of the tumor does not exceed 2 cm (for large it is malignant). The frequency of the disease is 1 case per million. Such a rare number causes erroneous diagnoses and improper treatment, and many doctors have never encountered it during their practice.
Hormone-active tumors
All benign pancreatic tumors are rare - 1-3 cases / million. If in men they make up 3.5%, in women - up to 16%. Most of them are endocrine. Sizes range from 0.5 cm to 15 cm. Any benign pancreatic neoplasms are always treated only by surgery. According to the secretion of hormones, they are divided into types:
- insulinoma - occupies 75%;
- VIPoma (more often, in 70% of cases, occurs in women after 45) - produces a vasoactive intestinal peptide;
- gastrinoma (affects middle-aged men more);
- glucagonoma - the frequency is 1 case per 20 million, more often in women, in 80% it is malignant.
Topography and anatomy of the pancreas
The pancreas is the most important internal organ in humans. It is an exo- and endocrine gland. It produces enzymes for digestion (trypsin, chymotrypsin, amylase, lipase) and hormones (glucagon and insulin) for carbohydrate metabolism. Insulin lowers glucose, and glucagon, on the contrary, increases. Her pathologies are not uncommon, so having an idea of her location and symptoms is worth more.
Where is the pancreas located and how to treat it? It is deployed in the abdominal cavity behind the stomach, adjoins it and the duodenum closely, at the level of 2 upper lumbar vertebrae.
KDP bends around the gland in the form of a horseshoe. The size of the adult gland is up to 20-25 cm, weight - 70-80 g. It has a head, body and tail.
The head reaches the bile duct, the tail near the spleen goes under the left hypochondrium. When viewed from the front, the projection will be 10-12 cm above the navel. Why know this? Because the pains during its inflammation will fall precisely on these zones.
Pancreatic disease
There are a lot of diseases in the pancreas and the treatment is usually conservative. But this does not apply to tumors. Here only radical measures. How does the pancreas hurt (symptoms)? In inflammatory processes, the most common are pain and digestive disorders. There are no gender differences. The pain is characterized by its girdling character and is localized in the left hypochondrium. It may not be associated with food intake, often accompanied by nausea, sometimes vomiting of acidic contents.
Appetite is always sharply reduced or absent, rumbling, bloating in the abdomen, and stool are unstable. In feces, there can often be admixtures of fat or undigested food.
Also, in acute inflammation, signs of intoxication are characteristic in the form of headache, tachycardia, weakness and sweating, the temperature may rise. The liver is enlarged.
How does the pancreas (symptoms) hurt in chronic pancreatitis? Here the pain is less intense, but frequent and associated with errors in nutrition. The danger of chronic pancreatitis is that it can lead to the development of tumors in the gland.
Etiology of insulin
The causes of pancreatic insulinoma are not known today. Some researchers tend to suggest the influence of genetic predisposition.
But risk factors provocateurs are known:
- malfunctioning of the adrenal gland and pituitary gland;
- stomach ulcer or duodenum;
- damage to the pancreas, chemical or mechanical;
- chronic pathology of the gastrointestinal tract;
- exhaustion of the body;
- eating disorders.
The pathogenesis of hypoglycemia with insulinoma
It has already been said that hyperinsulinism with insulinoma is not controlled. Normally, a drop in blood glucose leads to a drop in insulin.
With insulinoma, this does not happen. Each release of a portion of insulin causes a state of hypoglycemia.
In this case, the most sensitive are brain cells. Glucose for the brain is the only food and it has no carbohydrate reserves. Therefore, with insulinoma, first of all, dystrophic changes in the central nervous system develop.
The brain is not able to use free fatty acids circulating in the blood to feed itself. The hypoglycemic state stimulates the release into the blood of hormones of the contra-directional direction (norepinephrine, glucagon, cortisol, STH). They increase the activity of the sympathetic nervous system with an excess of adrenaline, i.e. adrenergic symptoms. This is a protective reaction of the body. The mechanism of glucose replenishment by breaking down glycogen in the liver (glycogenolysis), the formation of glucose from non-carbohydrate compounds (also occurs in the liver - gluconeogenesis), the oxidation of blood fatty acids and the formation of acetone bodies (also in the liver) are also triggered.
In all these processes, the already mentioned contra-hormonal hormones are involved . Metabolism is completely disturbed towards acidosis. All this time, healthy pancreatic cells continue to work - insulin production.
Tumor features
The morphology of the tumor, necessary for its detection: the formation looks like a dense encapsulated node, this does not immediately determine the degree of its benignity. Its color is from pink to brown, with malignancy it is more often brick red. Dimensions do not exceed 5 cm. During degeneration, metastases in the lymph nodes, lungs, nodes, liver, which are also hormone-active, will be detected.
Insulin classification
She is needed to choose treatment tactics. The first division is according to the degree of malignancy.
By the degree of distribution in the parenchyma, the pancreas is solitary (single) and multiple. Solitary are larger and rarely reborn; and multiple ones have the appearance of clusters with small dense nodules and early malignant.
At the location - in the tail, body or head.
Clinic
During insulinomas, the phases of seizures and the interictal period are distinguished. Symptoms of pancreatic insulinoma in the interictal period are absolutely not specific and are more often neurological in nature, which makes diagnosis difficult.
In the latent period, the only signs are: increased appetite, especially craving for sweets, obesity. Patients should carry sweets in case of hypoglycemia.
The following signs and symptoms of pancreatic insulinoma are considered specific:
- poor health and constant causeless weakness;
- pallor of the skin;
- constant sticky cold sweat;
- hand tremor;
- tachycardia.
Hypoglycemic syndrome: an attack occurs more often in the morning, before waking up, on an empty stomach. Associated with an overnight meal break. Accompanied by tremor of hands, tachycardia, clammy cold sweat, paresthesias, impaired behavior, visual hallucinations.
In severe cases, convulsions appear and a coma develops. Such patients, as it were, cannot wake up: for a long time they are disoriented in space, make some movements and repeat them, they answer monosyllables in simple terms.
All these are signs of impaired consciousness. Often the patient is like a drunk, can rush about and shout something, or sing and dance, answer out of place.
Epileptiform seizures are typical, they are longer, accompanied by hyperkinesis and the above symptoms. Similar conditions similar to the manifestation of epilepsy may develop: the patient outwardly travels correctly in any direction and then cannot explain how and why he ended up here. But there are no characteristic epileptoid personality changes here.
From the attack of the patient can be deduced by the introduction of glucose. After the attack, the patient does not remember anything, he has retrograde amnesia.
In the interictal period, there are symptoms of pancreatic insulinomas that occur in chronic hypoglycemia. Its effect on the central and autonomic nervous systems is manifested by impaired cranial nerves - 7 and 9 pairs - facial and glossopharyngeal, according to the central type. Because of this, asymmetry of the face, smoothness of the nasolabial folds, lowering of the corners of the mouth, loss of facial expressions, lacrimation, taste disturbance, the appearance of glossalgia and sore throat occur.
Pathological reflexes appear: Babinsky (stop extensor reflex), Rossolimo (flexor). These symptoms of pancreatic insulinoma are supplemented with signs of damage to the left hemisphere of the brain: thinking slows down, memory and attention decrease, memory failures are frequent, mental disability is reduced, apathy appears, professional skills are lost.
Moreover, it is so expressed that patients do not develop professionally, do not work in their specialty in simple jobs. Even if the operation to remove the insulinoma was successful, a decrease in intelligence and signs of encephalopathy remain. They do not leave and the previous social status does not return. In men, with frequent attacks of hypoglycemia, impotence develops.
Additional symptoms of insulinoma in a person who has malignant: the patient becomes cachectic, his stomach hurts and diarrhea worries. Non-specific symptoms lead to the fact that 75% of patients with insulinoma are unsuccessfully treated by neurologists and psychiatrists. Moreover, in 35% of cases, a diagnosis of epilepsy, a brain tumor or cerebrovascular accident is diagnosed in 15%, VVD in 11%, etc.
Diagnosis of insulinoma
A detailed medical history is required: the occurrence of hypoglycemia more often in the morning on an empty stomach, after skipping meals, before menstruation, or after physical work will be characteristic of the disease.
There is a triad of Whipple signs (pathognomonic signs) that make it possible to suspect the presence of insulinomas:
- fasting hypoglycemia;
- blood glucose at the time of the attack is below 2.7 mmol / l;
- withdrawal of the patient from an attack after glucose administration.
The level of insulin during an attack is always elevated even at the lowest glucose level. The level of C-peptide is also important for diagnosis; it is inadequately high.
Due to the fact that insulinoma is always very small, ultrasound diagnostics of pancreatic insulinomas and computed tomography are not very informative.
Today, an effective diagnostic method is pancreatic angiography. This is due to the fact that insulinomas and other tumors have a rich network of vessels.
Then determine the size and localization of insulinomas. Also, the diagnostic method is the conduct of an insulin provocation test.
To do this, glucose is injected intravenously, it raises endogenous insulin. At the same time, the ratio of insulin and glucose is normally less than 0.4, with insulinoma - the patient has much more than 0.4. In this situation, the diagnosis is specified by diagnostic laparoscopy, intraoperative pancreatic ultrasonography.
Complications of Insulinomas
The consequences of pancreatic insulinoma can concern both its benign tumor and malignancy. Rebirth itself is already a complication; it happens in 10% of cases. But even if this does not happen, it is noted:
- neurological symptoms with impaired functioning of the facial and glossopharyngeal nerve;
- impaired memory, vision, mental abilities;
- in men impotence is possible;
- obesity.
Conditions of hypoglycemia can lead to the development of coma, myocardial infarction.
Insulinoma treatment
In most cases, the treatment of pancreatic insulinoma is surgical. This leads to a complete recovery of the patient in 80% of cases. If it is not possible to carry out the operation, treatment with drugs that reduce insulin secretion is used. Fractional frequent carbohydrate nutrition is also important. To prevent attacks of hypoglycemia, glucose is administered.
Radical measures
Surgical treatment is preferable, its types: enucleation (tumor husking), pancreatic resection, pancreatoduodenal resection or total pancreatectomy, i.e. complete removal. In general, operations on the pancreas are always classified as complex.
But whether a person can live without a pancreas after surgery to remove it, it is impossible to predict. The more negative factors affect the body, the greater the percentage of complications. The volume of the operation depends on the location of the insulinoma and its size.
The glucose level is determined in dynamics directly during the operation. In 10% of cases, operations give complications: fistulas and abscesses of the abdominal cavity, peritonitis, pancreatitis, abscesses, pancreatic necrosis (leading to death). The operation is not performed if the patient himself does not want this or there are somatic pathologies.
Can a person live without a pancreas? Of course! But only subject to a healthy lifestyle and compliance with all the recommendations of a doctor.
If the tumor is malignant, has given multiple metastases and has become inoperable, chemotherapy is prescribed. It is carried out by “Streptozotocin”, “5-fluorouracil”, “Doxorubicin”, etc. Chemotherapy can help only in 60% of cases: this amount is explained by good sensitivity to “Streptozotocin”. In cases of tumor insensitivity to Streptozotocin, it is replaced with Adriamycin.
Also, if surgery is not possible, hypoglycemia is prevented. For this, hyperglycemic agents are used (adrenaline, noradrenaline, glucagon, corticosteroids).
To suppress insulin production, “Diazoxide" ("Proglikem", "Hyperstat") or "Octreotide (sandostatin) are prescribed. They reduce the severity of hypoglycemia attacks. But the GCS group has side effects - for their positive effect, doses are needed so that neuroendocrine ones can develop disorders of the type of Cushing's syndrome.
Diet for insulinoma
Diet should be only sparing. With insulinoma, the patient will need to abandon the use of salted, smoked, spicy, fatty and fried foods, as well as minimize carbonated drinks and coffee.
Preference is all those foods that contain fiber. Simple (refined) carbohydrates are completely excluded. These are sugar, cakes, pastries, chocolate, as well as products with high GKI: potatoes, white bread, muffins, whole milk.
The drinking regime is strengthened, you need to drink at least 2 liters of clean water per day, but in no case do not drink coffee and sweet soda.
Forecast
With benign insulinomas, the percentage of recovery in 80% of cases. In 3% of cases, relapse is possible. Mortality is 5-10%. With ectopic insulinomas, only conservative treatment is prescribed.
In case of pancreatic malignancy with insulin malignancy, the prognosis depends on metastases and localization of the tumor itself. The percentage of malignancy is 10%. 2-year survival rate of about 60%. From the moment of diagnosis of insulinoma, the patient is put on a lifelong medical examination by an endocrinologist and a neurologist.