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Background Hypoglycemia is a clinical situation characterized by a reduction in plasma glucose concentration to a level that may induce symptoms or signs such as altered mental status and/or sympathetic nervous system stimulation. The glucose level at which an individual becomes symptomatic is highly variable, 5/22/12

Pathophysiology

Hypoglycemic symptoms are related to sympathetic activation and brain dysfunction secondary to decreased levels of glucose. Stimulation of the sympathoadrenal nervous system leads to sweating, palpitations, tremulousness, anxiety, and hunger. Reduction in cerebral glucose availability (ie, neuroglycopenia) can manifest as confusion, difficulty with 5/22/12 concentration, irritability,

Etiology Causes of hypoglycemia are varied, but it is seen most often in diabetic patients. Hypoglycemia may result from medication changes or overdoses, infection, diet changes, metabolic changes over time, or activity changes; however, no acute cause may be found. Other causes include alimentary problems, 5/22/12

Fasting hypoglycemia Nesidioblastosis it is a rare cause of fasting hypoglycemia in infants and an extremely rare cause in adult. This condition is characterized by a diffuse budding of insulin-secreting cells from pancreatic duct epithelium and pancreatic microadenomas of such cells. Causes of fasting hypoglycemia

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Drugs Ethanol (including propranolol plus ethanol), haloperidol, pentamidine, quinine, salicylates, and sulfonamides ("sulfa drugs") have been associated with hypoglycemia. Other drugs that may be related to this condition include oral hypoglycemics, phenylbutazone, insulin, bishydroxycoumarin, p5/22/12

Surreptitious sulfonylurea use/abuse Factitious hypoglycemia or selfinduced hypoglycemia can be seen in healthcare workers or in relatives who care for diabetic family members at home. (see Type 1 Diabetes Mellitus and Type 2 Diabetes Mellitus for further discussion, including the diagnostic 5/22/12

Exogenous insulin Sources of exogenous insulin include insulin-producing tumors of pancreas and nonbeta-cell tumors. Insulin-producing tumors of pancreas Islet cell adenoma or carcinoma (insulinoma) is an uncommon and usually curable cause of fasting hypoglycemia and is most often 5/22/12 diagnosed in adults. It may occur as

Reactive hypoglycemia Reactive hypoglycemia can be idiopathic, due to alimentary problems, or a result of congenital enzyme deficiencies. Alimentary hypoglycemia is another form of reactive hypoglycemia that occurs in patients who have had previous upper gastrointestinal (GI) 5/22/12 surgical procedures (gastrectomy,

Congenital enzyme deficiencies include hereditary fructose intolerance, galactosemia, and leucine sensitivity of childhood. In hereditary fructose intolerance and galactosemia, an inherited deficiency of a hepatic enzyme causes acute inhibition of hepatic glucose output when fructose or galactose is ingested. Leucine provokes an 5/22/12 exaggerated insulin secretory

Other causes of hypoglycemia include the following, singly or in combination (eg, chronic renal failure and sulfonylurea ingestion): Autoimmune hypoglycemia: Insulin antibodies and insulin receptor antibodies Hormonal deficiencies: Hypoadrenalism (cortisol), 5/22/12 hypopituitarism (growth hormone) (in

Epidemiology The incidence of hypoglycemia in a population is difficult to ascertain. Patients and physicians frequently attribute symptoms (eg, anxiety, irritability, hunger) to hypoglycemia without documenting the presence of low blood sugar. The true prevalence of hypoglycemia, with blood sugar levels below 50 mg/dL, generally 5/22/12

Prognosis The prognosis of hypoglycemia depends on the cause of this condition, its severity, and its duration. If the cause of fasting hypoglycemia is identified and treated early, the prognosis is excellent. If the problem is not curable, such as an inoperable malignant tumor, the long-term 5/22/12

History The patient's medication and drug history should be reviewed carefully for potential causes of hypoglycemia. Inquire if the patient is taking any new medications. A history of insulin usage or ingestion of an oral hypoglycemic agent may be known, and possible toxic ingestion should be considered. Injecting a shot of 5/22/12

Neurogenic or neuroglycopenic symptoms Symptoms of hypoglycemia may be categorized as neurogenic (adrenergic) or neuroglycopenic. Sympathoadrenal activation symptoms include sweating, shakiness, tachycardia, anxiety, and a sensation of hunger. Neuroglycopenic symptoms include 5/22/12

Reactive hypoglycemic symptoms Reactive hypoglycemia seldom causes glucose levels to drop low enough to induce severe neuroglycopenic symptoms; therefore, a history of true loss of consciousness is highly suggestive of an etiology other than reactive hypoglycemia. 5/22/12

Gestational hypoglycemia In a study of maternal hypoglycemia, Pugh et al found that hypoglycemia occurred more frequently in women younger than 25 years and those who had a preexisting medical condition.[10] Hypoglycemia was less frequent in women whose prepregnancy body mass index (BMI) was 30 kg/m2. The investigators 5/22/12

Physical Examination Physical findings are nonspecific in hypoglycemia and generally are related to the central and autonomic nervous systems. Assess vital signs for hypothermia, tachypnea, tachycardia, hypertension, and bradycardia (neonates). The head, eyes, ears, nose, and 5/22/12 throat (HEENT) examination may

Diagnostic Considerations Because the consequences of hypoglycemia can be devastating and an antidote is readily available, diagnosis and treatment must be rapid in any patient with suspected hypoglycemia, regardless of the cause. Patients with no previous history of hypoglycemia require a complete workup to find a potentially 5/22/12

The following should also be considered when evaluating a patient with hypoglycemia: Hepatic disease: (eg, hepatic failure, cirrhosis, galactose intolerance, fructose intolerance, glycogen storage diseases) Transient ischemic attacks
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Cardiac dysrhythmia

Differential Diagnoses Addison Disease Adrenal Crisis Alcoholism Anxiety Disorders Cardiogenic Shock Hypopituitarism (Panhypopituitarism) Insulin Resistance

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Approach Considerations Search for a source of infection. Studies should be considered to rule out the possibility of a concurrent occult infection contributing to the new hypoglycemic episode (eg, complete physical examination, chest radiography (particularly in diabetic patients presenting with hypoglycemia), urinalysis, blood 5/22/12

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