title: Evolving management of insulinoma: Experience at a tertiary care centre.
abstract: OBJECTIVE
  Since our previous study in 2006, several new modalities for localization of cause of endogenous hyperinsulinemic hypoglycaemia such as multiphasic computed tomography (CT), multiphasic magnetic resonance imaging (MRI), endoscopic ultrasound (EUS), intraoperative ultrasound, and intra-arterial calcium infusion with arterial stimulation venous sampling (ASVS) have become available. Therefore, to evaluate the relative usefulness of various imaging modalities to guide future management in terms of diagnosis and patient care, we analyzed presentation and management of patients of endogenous hyperinsulinemic hypoglycaemia.
  
  
  METHODS
  In this retrospective study, medical records of patients admitted with endogenous hyperinsulinemic hypoglycaemia were retrieved. Data pertaining to clinical features, diagnosis, imaging, surgery and patient outcome were extracted. The localization of insulinoma by preoperative imaging techniques was compared with the findings at surgery to assess the accuracy of localization.
  
  
  RESULTS
  Fasting hypoglycaemia was present in all, and post-prandial hypoglycaemia (plasma glucose ≤50 mg/dl within four hours of meal) in 25.8 per cent. Mean duration of symptoms before reaching a diagnosis of hyperinsulinemic hypoglycaemia was 3.9 years. Mean duration of provocative fast was 21.8 h (range 6-48 h). Among the currently used imaging modalities, the sensitivity of localizing tumour was 79.3 per cent for multiphasic CT, 85 per cent for multiphasic MRI and 95 per cent for EUS. EUS detected tumour missed by both CT and MRI. All, except one of the operated patients, were cured by surgery.
  
  
  CONCLUSIONS
  Our results suggest that patients with insulinoma have a varied presentation. Multiphasic contrast-enhanced MRI/CT scan, EUS and ASVS may be complimentary in pre-operative localization.
authors.affiliation: Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Viveka P
authors.initials: VP
authors.lastname: Jyotsna
authors.affiliation: Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Sujoy
authors.initials: S
authors.lastname: Pal
authors.affiliation: Department of Radiology, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: D
authors.initials: D
authors.lastname: Kandasamy
authors.affiliation: Department of Radiology, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: S
authors.initials: S
authors.lastname: Gamanagatti
authors.affiliation: Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: P K
authors.initials: PK
authors.lastname: Garg
authors.affiliation: Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: N
authors.initials: N
authors.lastname: Raizada
authors.affiliation: Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Peush
authors.initials: P
authors.lastname: Sahni
authors.affiliation: Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: C S
authors.initials: CS
authors.lastname: Bal
authors.affiliation: Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: N
authors.initials: N
authors.lastname: Tandon
authors.affiliation: Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: A C
authors.initials: AC
authors.lastname: Ammini
mesh_terms: D000328:Adult; D000368:Aged; D002118:Calcium / Q000008:administration & dosage; D019468:Disease Management; D005260:Female; D006801:Humans; D007261:Infusions, Intra-Arterial; D007328:Insulin / Q000097:blood*; D007340:Insulinoma / Q000097:blood / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000628:therapy*; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D062606:Tertiary Care Centers; D014057:Tomography, X-Ray Computed; D014463:Ultrasonography
chemical_list: D007328:Insulin; D002118:Calcium