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Insulinom hund

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Insulinoma in dogs is a tumour of the pancreas that causes symptoms by producing excessive amounts of insulin, without needing food in the stomach to trigger its release into the bloodstream. As a consequence, blood sugar levels are reduced and patients feel light-headed and weak. They can also show symptoms such as reduced ability or enthusiasm to exercise and even fainting, particularly after prolonged periods without eating.

Insulinoma in dogs can be a challenging condition to diagnose because

The symptoms are not specific to this condition, and
Blood tests can suggest the presence of a relative imbalance between insulin and blood glucose but are rarely conclusive.

Once a presumed diagnosis has been made on the basis of blood glucose and insulin measurements, canine insulinoma cases are managed by first checking for evidence of spread using abdominal ultrasound and chest x-rays.

Dogs with insulinoma are treated according to how much of a problem they have. With cases that have an apparently solitary lump in the pancreas, surgery can be performed. Patients can also have spread to the lymph nodes or the liver; in these cases surgery is unlikely to have a beneficial effect and so medical management is instituted.

Life expectancy following a diagnosis of insulinoma in dogs is related to how much of a problem the patient has and the development of post-operative complications. Patients that are amenable to surgery undergo partial pancreatectomy. Patients who are not good surgical candidates receive medical therapy, initially solely with prednisolone.

Previous reports in the literature describe average life expectancies of approximately one year for patients undergoing surgery and 2½ months for medical management (Tobin et al 1999). At Davies Veterinary Specialists, the outcomes appear to be significantly improved by comparison, with an average life expectancy following surgery of approximately 18 months. For patients who have achieved normal blood glucose control post-operatively, the average survival time is in excess of 3½ years (Polton et al 2006).

Tobin, R. L., Nelson, R. W., Lucroy, M. D., Wooldridge, J. D. & Feldman, E. C. (1999) Outcome of surgical versus medical treatment of dogs with beta cell neoplasia: 39 cases (1990-1997). Journal of the American Veterinary Medical Association 215, 226-230

G. A. Polton, R. N. White, M. J. Brearley, J. M. Eastwood (2007)

Improved survival in a retrospective cohort of 28 dogs with insulinoma Journal of Small Animal Practice 48, 151-156

Hundarnas insulinom symtom

Hundarnas insulinom hänvisar till ett tillstånd där en tumör utvecklas i hundens bukspottkörteln. Till följd av denna tumör, bukspottskörteln börjar producera stora mängder av insulin. Närvaro av insulin minskar blodsockernivån i hunden. Insulinom kan orsaka hypoglykemi hos hundar, och tidig identifiering är viktigt för snabb behandling.

På grund av dess minskade blodsockernivåer tenderar en hund som är drabbade Hundarnas insulinom att agera trött och svag. Han kan vara ointresserad av lek och motion och även om han är intresserad, han kan tröttna snabbt.

Viktökning

Eftersom mängden insulin i hennes kropp påverkar hur hennes kropp reagerar till mat och näring och håglöshet som medföljer Hundarnas insulinom, kommer att hunden lägga på mer vikt. Detta inträffar även om det inte skett en förändring i hundens kost eller en ökning av hennes aptit.

Överdriven aptit

Vissa hundar kommer bevis överdriven aptit när de påverkas av Hundarnas insulinom. De kan ständigt ber om mat eller Sök efter den när de har ätit en hel måltid.

Svaghet/svimning

På grund av förändringar i sitt blodsocker, kan hunden plötsligt verka svag eller ostadig på benen. Denna brist på samordning kan komma och gå, och i vissa fall hunden kan även svimma. Enligt Davies veterinärmedicinska specialister händer denna svimning ofta när hunden inte har ätit på ett tag.

Muskel skakningar

En hund som påverkas av de stora mängder av onödiga insulin i kroppen kan verka skakig och hon kan vara offer för muskel skakningar. Detta kan lägga till hundens bristen på samordning.

Insulinom hund

Wednesday, May 15, 2013

Insulinoma in Dogs, Cat, and Ferrets: Confirming the Diagnosis

Insulinoma, or functional beta-cell tumor, originates from the islet cells of the endocrine portion of the pancreas (1,2). Insulinoma has been described most commonly in dogs and ferrets, and less commonly in cats. Although insulinoma cells produce a variety of polypeptides, most animals with insulinoma are examined because of clinical signs related to hyperinsulinism and resultant hypoglycemia.

Insulinoma has been reported in dogs ranging from 3-15 years old but is most common in dogs older than 8 years old (3-8). Insulinoma is very common in domestic ferrets, with an age range from 2-7 years (9-11). No sex predilection has been reported in dogs, but male ferrets seem to be affected more commonly than females. Insulinoma appears to be a rare condition in cats, with only five cats having been reported; these cats ranged in age from 12-17 years (12-15).

Clinical signs in animals with insulinoma are caused by hyperinsulinism, which leads to hypoglycemia. In response to a low blood glucose concentration, catecholamines, glucagon, cortisol, ACTH, and growth hormone are released.

Ferrets with insulinoma also commonly show signs of weakness and lethargy (9-11). As in dogs, these symptoms may be episodic. However, seizures are relatively uncommon in this species. Ptyalism is a clinical sign associated with insulinoma in ferrets that has not been described in dogs. The cause of this sign is not known, but ptyalism in ferrets may indicate nausea.

A complete history may lead the clinician to suspect that a patient’s presenting clinical signs are related to hypoglycemia, and thus consider insulinoma as a differential diagnosis. A plasma glucose concentration of 40 mg/dl (2 mmol/L) or less supports the conclusion that the signs are caused by hypoglycemia (16).

In addition to insulinoma, there are many other possible causes of hypoglycemia in animals (1,2,16,21) (Table 2).

Many of these differential diagnoses can be ruled out quickly during the initial history and physical examination. After consideration of these diseases is eliminated, insulinoma should be seriously considered in a mature patient with clinical signs of hypoglycemia.

Hyperinsulinism is best diagnosed by the interpretation of serum insulin and glucose concentrations obtained from the patient at the same time. If the clinician suspects hyperinsulinism at the time of initial examination of an animal showing signs of hypoglycemia, serum samples for glucose and insulin measurements are best obtained at that time.

Whenever possible, abdominal ultrasound should be performed in dogs and cats with suspected insulinoma. It can be difficult to detect small pancreatic nodules via ultrasound, but it may be helpful in identifying abdominal metastases (2,22,23). In all species, abdominal ultrasonography may help rule out other neoplasms as a cause of hypoglycemia.

Elie MS, Zerbe CA. Insulinoma in dogs, cats, and ferrets. Compend Contin Educ Vet 1995;17:51-59.
Kintzer PP. Insulinoma and other gastrointestinal tract tumours In: Mooney CT, Peterson ME, eds. BSAVA Manual of Canine and Feline Endocrinology. Quedgeley, Gloucester: British Small Animal Veterinary Association, 2012;148-155.
Kruth SA, Feldman EC, Kennedy PC. Insulin-secreting islet cell tumors: establishing a diagnosis and the clinical course for 25 dogs. J Am Vet Med Assoc 1982;181:54-58.
Leifer CE, Peterson ME, Matus RE. Insulin-secreting tumor: diagnosis and medical and surgical management in 55 dogs. J Am Vet Med Assoc 1986;188:60-64.
Schrauwen E. Clinical peripheral polyneuropathy associated with canine insulinoma. Vet Rec 1991;128:211-212.
Trifonidou MA, Kirpensteijn J, Robben JH. A retrospective evaluation of 51 dogs with insulinoma. Vet Q 1998;20 Suppl 1:S114-115.
Madarame H, Kayanuma H, Shida T, et al. Retrospective study of canine insulinomas: eight cases (2005-2008). J Vet Med Sci 2009;71:905-911.
Goutal CM, Brugmann BL, Ryan KA. Insulinoma in dogs: a review. J Am Anim Hosp Assoc 2012;48:151-163.
Caplan ER, Peterson ME, Mullen HS, et al. Diagnosis and treatment of insulin-secreting pancreatic islet cell tumors in ferrets: 57 cases (1986-1994). J Am Vet Med Assoc 1996;209:1741-1745.
Ehrhart N, Withrow SJ, Ehrhart EJ, et al. Pancreatic beta cell tumor in ferrets: 20 cases (1986-1994). J Am Vet Med Assoc 1996;209:1737-1740.
Weiss CA, Williams BH, Scott MV. Insulinoma in the ferret: clinical findings and treatment comparison of 66 cases. J Am Anim Hosp Assoc 1998;34:471-475.
McMillan FD, Feldman EC. Functional pancreatic islet cell tumor in a cat. J Am Anim Hosp Assoc 1985;21:741-746.
Hawks D, Peterson ME, Hawkins KL, et al. Insulin-secreting pancreatic (islet cell) carcinoma in a cat. J Vet Intern Med 1992;6:193-196.
Kraje AC. Hypoglycemia and irreversible neurologic complications in a cat with insulinoma. J Am Vet Med Assoc 2003;223:812-814.
Greene SN, Bright RM. Insulinoma in a cat. J Small Anim Pract 2008;49:38-40.
Schoeman JP. Investigation of hypoglycaemia In: Mooney CT, Peterson ME, eds. BSAVA Manual of Canine and Feline Endocrinology. Fourth ed. Quedgeley, Gloucester: British Small Animal Veterinary Association, 2012;259-264.
Schrauwen E, Van Ham L, Desmidt M, et al. Peripheral polyneuropathy associated with insulinoma in the dog: Clinical, pathological, and electrodiagnostic features. Prog Vet Neurol 1996;7:16-19.
Braund KG, Steiss JE, Amling KA, et al. Insulinoma and subclinical peripheral neuropathy in two dogs. J Vet Intern Med 1987;1:86-90.
Ariamkina OL, Doroshenko GM, Petrenko LV. On diagnostic value of Whipple's triad: a case of insulinoma diagnosis. Klin Med (Mosk) 1997;75:61-63.
Hirshberg B, Livi A, Bartlett DL, et al. Forty-eight-hour fast: the diagnostic test for insulinoma. J Clin Endo Metab 2000;85:3222-3226.
Murphy LA, Coleman AE. Xylitol toxicosis in dogs. Vet Clin North Am Small Anim Pract 2012;42:307-312.
Goutal CM, Brugmann BL, Ryan KA. Insulinoma in dogs: a review. J Am Anim Hosp Assoc 2012;48:151-163.
Robben JH, Pollak YW, Kirpensteijn J, et al. Comparison of ultrasonography, computed tomography, and single-photon emission computed tomography for the detection and localization of canine insulinoma. J Vet Intern Med 2005;19:15-22.

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Dr. Mark E. Peterson

About Insights into Veterinary Endocrinology

Please also read my Animal Endocrine blog for pet owners.

Insulinoma

Insulinoma is a rare malignant neuroendocrine neoplasia of the β-cells of the canine pancreas [2] .

Beta cells comprise 60% to 70% of pancreatic islet cells [3] . Insulinomas have been shown to produce various polypeptides (somatostatin, glucagon, serotonin and pancreatic polypeptide) [4] . Most patients only have clinical signs of hyperinsulinism [5] .

Approximately 90% of insulinomas in dogs are malignant and metastasize mainly to the regional lymph nodes, the liver and the omentum [6] , causing regional lymphadenopathy.

Insulinomas are commonly diagnosed in middle-aged to old, and large breeds such as Labrador Retrievers and German Shepherds are over-represented.

The clinical signs of hypoglycemia often seen after fasting, exercise, excitement, and eating, and are rapidly alleviated by the administration of glucose. Symptoms become more frequent as the disease progresses and are the result of both decreased glucose supply to the brain and stimulation of the counter-regulatory sympathoadrenal system [7] . Signs include those related to hypoglycemia (lethargy, seizures and ataxia) [8] and adrenergic effects (tachycardia, tremors, nervousness and polyphagia).

A tentative diagnosis can be made on laboratory evidence of persistent hypoglycemia (< 3.3 mmol/L) supportive by ultrasonographic, CT or MRI imaging showing a central abdominal tumor [10] .

A definitive diagnosis of insulinoma is made following laboratory demonstration of an inappropriately high serum insulin concentration during a time of hypoglycemia (typically > 71.7 pmol/L) [11] . Insulin detection usually requires ELISA assaying by a reference laboratory [12] .

Histological biopsies of the pancreas are usually confirmatory. Clinical staging is usually performed for prognositcation.

Stage I - Insulinoma confined to pancreas
Stage II - Insulinoma with metastasis to regional lymph node
Stage III - Insulinoma with metastasis to distant organs

A differential diagnosis would include hypoglycemia of extrapancreatic tumors which secrete insulin-like hormones, including hyperinsulinism, hepatic dysfunction, adrenocortical insufficiency, hypopituitarism, extrapancreatic tumors, starvation, and sepsis.

Treatment of acute hypoglycemia requires intravenous administration of 2.5% to 5% dextrose in parenteral fluids, such as 0.9% NaCl or Ringer’s solution. Dogs that are convulsing should be given IV 0.5 g/kg dextrose slowly over 5 minutes [13] .

Surgical treatment invariably requires pancreatectomy, and surgery is generally considered to be palliative, as microscopic metastases are usually present even when there are no visible metastatic lesions. Postoperative complications included pancreatitis, persistent hypoglycemia, hyperglycemia and diabetes mellitus, pancreatic pseudocyst, acquired seizures unrelated to hypoglycemia, and diffuse peripheral neuropathy.

Medical management includes a change in diet to a high protein, high fat, and complex carbohydrate diet, feeding small meals 3 to 6 times a day. Exercise restriction is important to minimize potential hypoglycemia episodes.

Chemotherapy is often indicated, due to the metastatic nature of this disease. Drugs include

prednisolone - stimulates hepatic glycogenolysis while inhibiting insulin effects on peripheral tissues)
alloxan
diazoxide - antihypertensive that controls hypoglycemia [14]
streptozocin
octreotide - still under debate [15]

Dogs with tumors confined to the pancreas (stage I) or with metastasis to regional lymph nodes (stage II) have a median survival time of approximately 1 - 2 years after surgery [16] , whereas dogs with distant metastasis (stage III) have a median survival time of less than 6 months after surgery [17] .

The long-term prognosis after surgical resection of canine insulinoma is poor due to re-occurrence [18] Histological staging and tumor size are good indices for expectant survival time [19] [20] .