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Hypoglycemia
Classification and external resources
Glucose test
ICD-10 E16.0-E16.2
ICD-9 250.8, 251.0, 251.1, 251.2, 270.3, 775.6, 962.3
DiseasesDB 6431
MedlinePlus 000386
eMedicine emerg/272  med/1123 med/1939 ped/1117
MeSH D007003

Hypoglycemia (Hypoglycaemia in British English) is the medical term for a pathologic state produced by a lower than normal level of glucose (sugar) in the blood. The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The International Statistical Classification of Diseases and Related Health Problems 10th Revision ( ICD -10) is a coding of diseases and signs symptoms abnormal findings E00-E35 - Endocrine diseases (E00-E07 Thyroid gland / Thyroid hormone ( Congenital iodine-deficiency syndrome ( E00-E35 - Endocrine diseases (E00-E07 Thyroid gland / Thyroid hormone ( Congenital iodine-deficiency syndrome ( The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. The Diseases Database is a free Website that provides information about the relationships between medical conditions Symptoms, and Medications. MedlinePlus, with the MedlinePlus Medical Encyclopedia, is a website network containing Health information from the world's largest medical Library eMedicine is an online clinical medical knowledge base that was founded in 1996 by Scott Plantz and Richard Lavely two medical doctors Medical Subject Headings ( MeSH) is a huge Controlled vocabulary (or metadata system for the purpose of indexing journal articles and books British English or UK English ( BrE, BE, en-GB) is the broad term used to distinguish the forms of the English language used in the Pathology (from Greek grc πάθος pathos, "fate harm" and grc -λογία -logia) is the study and Glucose (Glc a Monosaccharide (or simple Sugar) also known as grape sugar, is an important Carbohydrate in Biology. Blood sugar, used in a physiological context is a misnomer and misleading The term hypoglycemia literally means "under-sweet blood" (Gr. hypo-, glykys, haima). Greek (el ελληνική γλώσσα or simply el ελληνικά — "Hellenic" is an Indo-European language, spoken today by 15-22 million people mainly The term also refers to a putative condition that is scientifically disputed and which is perhaps more properly considered as a part of "alternative" medicine. This is covered at the end of this article.

Hypoglycemia can produce a variety of symptoms and effects but the principal problems arise from an inadequate supply of glucose as fuel to the brain, resulting in impairment of function (neuroglycopenia). The brain is the center of the Nervous system in animals All Vertebrates and the majority of Invertebrates have a brain Neuroglycopenia is a medical term that refers to a shortage of Glucose (glycopenia in the Brain, usually due to Hypoglycemia. Derangements of function can range from vaguely "feeling bad" to coma and (rarely) permanent brain damage or death. In Medicine, a coma (from the Greek koma, meaning deep sleep is a profound state of Unconsciousness. Hypoglycemia can arise from many causes and can occur at any age.

The most common forms of moderate and severe hypoglycemia occur as a complication of treatment of diabetes mellitus with insulin or certain oral medications. Diabetes mellitus (ˌdaɪəˈbiːtiːz or /ˌdaɪəˈbiːtəs/ /məˈlaɪtəs/ or /ˈmɛlətəs/ often referred to simply as diabetes ( Ancient Greek: grc Insulin is a Hormone with intensive effects on both metabolism and several other body systems (eg vascular compliance Anti-diabetic drugs treat Diabetes mellitus by lowering Glucose levels in the blood Hypoglycemia is usually treated by the ingestion or administration of dextrose, or foods digestible to glucose. Glucose (Glc a Monosaccharide (or simple Sugar) also known as grape sugar, is an important Carbohydrate in Biology.

Endocrinologists (specialists in hormones, including those which regulate glucose metabolism) typically consider the following criteria (referred to as Whipple's triad) as proving that individual's symptoms can be attributed to hypoglycemia:

  1. Symptoms known to be caused by hypoglycemia
  2. Low glucose at the time the symptoms occur
  3. Reversal or improvement of symptoms or problems when the glucose is restored to normal

However, not everyone has accepted these suggested diagnostic criteria, and even the level of glucose low enough to define hypoglycemia has been a source of controversy in several contexts. Endocrinology (from Greek grc ἔνδον endon, "within" grc κρῑνω krīnō, "to separate" and grc -λογία See also Gluconeogenesis, which carries out a process wherein glucose is synthesized rather than catabolized Whipple's triad is a collection of three criteria (called Whipple's criteria) that suggest a patient's Symptoms result from Hypoglycemia. A symptom' (from Greek σύμπτωμα, "accident misfortune that which befalls" from συμπίπτω, "I befall" from For many purposes, plasma glucose levels below 70 mg/dl or 3. Blood plasma is the Liquid component of Blood, in which the Blood cells are suspended 9 mmol/L are considered hypoglycemic; these issues are detailed below.

Contents

Defining hypoglycemia

No single glucose value alone serves to define the medical condition termed hypoglycemia for all people and purposes. Throughout the 24 hour cycles of eating, digestion, and fasting, blood plasma glucose levels are generally maintained within a range of 70-140 mg/dL (3. 9-7. 8 mmol/L) for healthy humans. [1] Although 60 or 70 mg/dL (3. 3 or 3. 9 mmol/L) is commonly cited as the lower limit of normal glucose, different values (typically below 40, 50, 60, or 70 mg/dL) have been defined as low for different populations, clinical purposes, or circumstances.

The precise level of glucose considered low enough to define hypoglycemia is dependent on (1) the measurement method, (2) the age of the person, (3) presence or absence of effects, and (4) the purpose of the definition. While there is no disagreement as to the normal range of blood sugar, debate continues as to what degree of hypoglycemia warrants medical evaluation or treatment, or can cause harm. [2][3][4]

This article expresses glucose in milligrams per deciliter (mg/dL or mg/100 mL) as is customary in the United States, while millimoles per litre (mmol/L or mM) are the SI (International System) units used in most of the rest of the world. The litre or liter (see spelling differences) is a unit of Volume. Glucose concentrations expressed as mg/dL can be converted to mmol/L by dividing by 18. 0 g/mol (the molar mass of glucose). Molar mass, symbol M, is the Mass of one mole of a substance ( Chemical element or Chemical compound) For example, a glucose concentration of 90 mg/dL is 5. 0 mmol/L or 5. 0 mM.

Measurement method

Blood glucose levels discussed in this article are venous plasma or serum levels measured by standard, automated glucose oxidase methods used in medical laboratories. Blood sugar, used in a physiological context is a misnomer and misleading In the Circulatory system, a vein is a Blood vessel that carries Blood back toward the Heart (as opposed to Artery, a blood vessel Blood plasma is the Liquid component of Blood, in which the Blood cells are suspended The glucose oxidase enzyme (GOx ( binds to beta-D-glucose (an Isomer of the six-carbon sugar Glucose) and aids in breaking the sugar down into its Metabolites A medical laboratory or clinical laboratory is a Laboratory where tests are done on clinical specimens in order to get information about the Health For clinical purposes, plasma and serum levels are similar enough to be interchangeable. Arterial plasma or serum levels are slightly higher than venous levels, and capillary levels are typically in between. Arteries are Blood vessels that carry blood away from the Heart. Capillaries are the smallest of a body's Blood vessels measuring 5-10 μm in diameter which connect Arterioles and Venules and enable the interchange [5] This difference between arterial and venous levels is small in the fasting state but is amplified and can be greater than 10% in the postprandial state. [6] On the other hand, whole blood glucose levels (e. g. , by fingerprick meters) are about 10%-15% lower than venous plasma levels. A glucose meter (or glucometer) is a Medical device for determining the approximate concentration of Glucose in the Blood. [5] Furthermore, available fingerstick glucose meters are only warranted to be accurate to within 15% of a simultaneous laboratory value under optimal conditions, and home use in the investigation of hypoglycemia is fraught with misleading low numbers. In Medicine, some Blood tests are conducted on Venous blood obtained by fingerprick. [7][8] In other words, a meter glucose reading of 39 mg/dL could be properly obtained from a person whose laboratory serum glucose was 53 mg/dL; even wider variations can occur with "real world" home use. Ironically, most meters sold are routinely tested for accuracy at the high-end of the scale, sometimes up to 800 mg/dL, despite the fact that there is little immediate danger from hyperglycemia, whereas there is very real immediate danger from hypoglycemia, making accuracy at the low-end extremely critical. Hyperglycemia, hyperglycaemia, or high blood sugar is a condition in which an excessive amount of Glucose circulates in the Blood plasma

Two other factors significantly affect glucose measurement: hematocrit and delay after phlebotomy. The disparity between venous and whole blood concentrations is greater when the hematocrit is high,[6] as in newborn infants, or adults with polycythemia. The hematocrit ( Ht or HCT) or packed cell volume ( PCV) or erythrocyte volume fraction (EVF is the proportion of Blood Polycythemia (or polycythaemia or erythrocytosis) is a condition in which there is a net increase in the total number of Blood cells, primarily Red High neonatal hematocrits are particularly likely to confound glucose measurement by meter. Second, unless the specimen is drawn into a fluoride tube or processed immediately to separate the serum or plasma from the cells, the measurable glucose will be gradually lowered by in vitro metabolism of the glucose at a rate of approximately 7 mg/dL/hr, or even more in the presence of leukocytosis. Sodium fluoride is the Chemical compound with the formula NaF Leukocytosis is a raised white blood cell count (the Leukocyte count above the normal range [9][10][6]

Age differences

Surveys of healthy children and adults show that plasma glucoses below 60 mg/dL (3. 3 mM) or above 100 mg/dL (5. 6 mM) are found in less than 5% of samples after an overnight fast. [11] In infants and young children up to 10% have been found to be below 60 mg/dL after an overnight fast. As the duration of fasting is extended, plasma glucose levels can fall further, even in healthy people. In other words, many healthy people can occasionally have glucose levels in the hypoglycemic range without symptoms or disease.

The normal range of newborn blood sugars continues to be debated. Surveys and experience have revealed blood sugars often below 40 mg/dL (2. 2 mM), rarely below 30 mg/dL (1. 7 mM), in apparently healthy full-term infants on the first day after birth. It has been proposed that newborn brains are able to use alternate fuels when glucose levels are low more readily than adults. Experts continue to debate the significance and risk of such levels, though the trend has been to recommend maintenance of glucose levels above 60-70 mg/dL after the first day after birth. In ill, undersized, or premature newborns, low blood sugars are even more common, but there is a consensus that sugars should be maintained at least above 50 mg/dL (2. Birth weight is the weight of a baby at its birth. It has direct links with the Gestational age at which the child was born and can be estimated 8 mM) in such circumstances. Some experts advocate 70 mg/dL as a therapeutic target, especially in circumstances such as hyperinsulinism where alternate fuels may be less available. Hyperinsulinemic hypoglycemia describes the condition and effects of low blood Glucose caused by excessive Insulin.

Presence or absence of effects

Research in healthy adults shows that mental efficiency declines slightly but measurably as blood glucose falls below 65 mg/dL (3. 6 mM) in many people. Hormonal defense mechanisms (adrenaline and glucagon) are activated as it drops below a threshold level (about 55 mg/dL for most people), producing the typical symptoms of shakiness and dysphoria. Hormones (from Greek ὁρμή - "impetus" are chemicals released by cells that affect cells in other parts of the body Glucagon is an important Hormone involved in Carbohydrate metabolism. Dysphoria (from Greek δύσφορος (dysphoros from δυσ- difficult and φέρω to bear is generally characterized as an unpleasant or uncomfortable mood such as sadness On the other hand, obvious impairment does not often occur until the glucose falls below 40 mg/dL, and up to 10% of the population may occasionally have glucose levels below 65 in the morning without apparent effects. Brain effects of hypoglycemia, termed neuroglycopenia, determine whether a given low glucose is a "problem" for that person, and hence some people tend to use the term hypoglycemia only when a moderately low glucose is accompanied by symptoms.

Even this criterion is complicated by the facts that A) hypoglycemic symptoms are vague and can be produced by other conditions; B) people with persistently or recurrently low glucose levels can lose their threshold symptoms so that severe neuroglycopenic impairment can occur without much warning; and C) many measurement methods (especially glucose meters) are imprecise at low levels.

Diabetic hypoglycemia represents a special case with respect to the relationship of measured glucose and hypoglycemic symptoms for several reasons. Diabetic hypoglycemia describes a low blood glucose level occurring in a person with Diabetes mellitus. Although home glucose meter readings are sometimes misleading, the probability that a low reading accompanied by symptoms represents real hypoglycemia is higher in a person who takes insulin. Second, the hypoglycemia has a greater chance of progressing to more serious impairment if not treated, compared to most other forms of hypoglycemia that occur in adults. Third, because glucose levels are above normal most of the time in people with diabetes, hypoglycemic symptoms may occur at higher thresholds than in people who are normoglycemic most of the time. For all of these reasons, people with diabetes usually use higher meter glucose thresholds to determine hypoglycemia.

Purpose of definition

For all of the reasons explained in the above paragraphs, deciding whether a blood glucose in the borderline range of 45-75 mg/dL (2. 5-4. 2 mM) represents clinically problematic hypoglycemia is not always simple. This leads people to use different "cutoff levels" of glucose in different contexts and for different purposes.

Pathophysiology

Like most animal tissues, brain metabolism depends primarily on glucose for fuel in most circumstances. Metabolism is the set of Chemical reactions that occur in living Organisms in order to maintain Life. A limited amount of glucose can be derived from glycogen stored in astrocytes, but it is consumed within minutes. Glycogen is a Polysaccharide of Glucose (Glc which functions as the secondary short term energy storage in Animal cells Astrocytes (also known collectively as astroglia) are characteristic star-shaped glial cells in the Brain and Spinal cord. For most practical purposes, the brain is dependent on a continual supply of glucose diffusing from the blood into the interstitial tissue within the central nervous system and into the neurons themselves. In Vertebrates the central nervous system ( CNS) is the part of the Nervous system which is enclosed in the Meninges. Neurons (ˈnjuːɹɒn also known as neurones and nerve cells) are responsive cells in the Nervous system that process and transmit information

Therefore, if the amount of glucose supplied by the blood falls, the brain is one of the first organs affected. In most people, subtle reduction of mental efficiency can be observed when the glucose falls below 65 mg/dl (3. 6 mM). Impairment of action and judgement usually becomes obvious below 40 mg/dl (2. 2 mM). Seizures may occur as the glucose falls further. An epileptic seizure is caused by excessive and/or hypersynchronous electrical Neuronal activity and is usually self-limiting As blood glucose levels fall below 10 mg/dl (0. 55 mM), most neurons become electrically silent and nonfunctional, resulting in coma. These brain effects are collectively referred to as neuroglycopenia.

The importance of an adequate supply of glucose to the brain is apparent from the number of nervous, hormonal and metabolic responses to a falling glucose level. Most of these are defensive or adaptive, tending to raise the blood sugar via glycogenolysis and gluconeogenesis or provide alternative fuels. Glycogenolysis (also known as "Glycogenlysis" is the Catabolism of Glycogen by removal of a Glucose monomer through cleavage with inorganic Gluconeogenesis (abreviated GNG) is a Metabolic pathway that results in the generation of Glucose from non- Carbohydrate carbon substrates such If the blood sugar level falls too low the liver converts a storage of glycogen into glucose and releases it into the bloodstream, to prevent the person going in to a diabetic coma, for a short period of time. Diabetic coma is a Medical emergency in which a person with Diabetes mellitus is Comatose (unconscious because of one of the acute complications

Brief or mild hypoglycemia produces no lasting effects on the brain, though it can temporarily alter brain responses to additional hypoglycemia. Prolonged, severe hypoglycemia can produce lasting damage of a wide range. This can include impairment of cognitive function, motor control, or even consciousness. The likelihood of permanent brain damage from any given instance of severe hypoglycemia is difficult to estimate, and depends on a multitude of factors such as age, recent blood and brain glucose experience, concurrent problems such as hypoxia, and availability of alternative fuels. The vast majority of symptomatic hypoglycemic episodes result in no detectable permanent harm. [12]

Signs and symptoms

Hypoglycemic symptoms and manifestations can be divided into those produced by the counterregulatory hormones (epinephrine/adrenaline and glucagon) triggered by the falling glucose, and the neuroglycopenic effects produced by the reduced brain sugar.

Adrenergic manifestations

Glucagon manifestations

Neuroglycopenic manifestations

Not all of the above manifestations occur in every case of hypoglycemia. A palpitation (medical term ectopic heart beat) is an abnormal awareness of the beating of the Heart, whether it is too slow too fast irregular The pupil is the hole that is located in the center of the iris of the eye and that controls the amount of light that enters the Eye. Paresthesia (pron /ˌpɛɹɪsˈθiʒə/ paraesthesia in British English, pron Hunger is a feeling experienced usually followed by a desire to Eat. Borborygmus (plural borborygmi) (from Greek βορβορυγμός) also known as stomach growling or rumbling is the rumbling Sound Nausea ( Latin: Nausea, Greek:, " Sea-sickness " also called wamble) is the sensation of unease and discomfort Vomiting (also called throwing up, emesis) is the forceful expulsion of the contents of one's Stomach through the Mouth and sometimes the Abdominal pain can be one of the Symptoms associated with transient disorders or serious disease A headache ( cephalalgia in medical terminology is a condition of pain in the Head; sometimes Neck or upper back pain may also be interpreted Anxiety is a physiological and psychological state characterized by Cognitive, Somatic, Emotional and Behavioral components Rage, in Psychiatry, is a mental state that is one extreme of the intensity spectrum of Anger. Sleep is a Natural state of bodily rest observed throughout the animal kingdom Amnesia (from Greek) is a condition in which Memory is disturbed Delirium is an acute and relatively sudden (developing over hours to days decline in attention-focus perception and Cognition. Diplopia, commonly known as double vision, is the simultaneous Perception of two images of a single object Automatic behavior, from the Greek automatismos or self action is the spontaneous production of often purposeless verbal or motor behavior without conscious self-control or Ataxia (from Greek α- as a negative prefix + -τάξις, meaning "lack of order" is a neurological sign and symptom consisting Drunkenness or inebriation is the state of being intoxicated by consumption of Alcoholic beverages to a degree that mental and physical faculties are noticeably Paralysed redirects here For other uses see xx Paralysed (disambiguation Paralysis is the complete loss of Muscle function Hemiparesis is the partial Paralysis of one side of the body It is generally caused by lesions of the Corticospinal tract, which runs down from the cortical Paresthesia (pron /ˌpɛɹɪsˈθiʒə/ paraesthesia in British English, pron A headache ( cephalalgia in medical terminology is a condition of pain in the Head; sometimes Neck or upper back pain may also be interpreted An epileptic seizure is caused by excessive and/or hypersynchronous electrical Neuronal activity and is usually self-limiting There is no consistent order to the appearance of the symptoms, if symptoms even occur. Specific manifestations may vary by age and by severity of the hypoglycemia. In young children, vomiting can sometimes accompany morning hypoglycemia with ketosis. Ketosis (kiːˈtoʊsɪs is a state in Metabolism occurring when the Liver excessively converts fat into fatty acids and Ketone In older children and adults, moderately severe hypoglycemia can resemble mania, mental illness, drug intoxication, or drunkenness. Mania (from Greek μανία and that from μαίνομαι - mainomai, "to rage to be furious" is a severe medical condition In the elderly, hypoglycemia can produce focal stroke-like effects or a hard-to-define malaise. A stroke is the rapidly developing loss of brain functions due to a disturbance in the blood vessels supplying blood to the brain The symptoms of a single person may be similar from episode to episode, but are not necessarily so and may be influenced by the speed at which glucose levels are dropping, and previous incidence.

In newborns, hypoglycemia can produce irritability, jitters, myoclonic jerks, cyanosis, respiratory distress, apneic episodes, sweating, hypothermia, somnolence, hypotonia, refusal to feed, and seizures or "spells". Myoclonus (maɪˈɒklənəs is brief involuntary twitching of a Muscle or a group of muscles Cyanosis is a blue coloration of the Skin and mucous membranes due to the presence of deoxygenated Hemoglobin in Blood vessels near the skin surface Hypothermia is a condition in which an organism's temperature drops below that required for normal Metabolism and bodily functions Hypotonia is a condition of abnormally low Muscle tone (the amount of tension or resistance to movement in a muscle often involving reduced muscle strength Hypoglycemia can resemble asphyxia, hypocalcemia, sepsis, or heart failure. In Medicine, hypocalcaemia is the presence of low serum Calcium levels in the Blood, usually taken as less than 2 Sepsis is a serious medical condition characterized by a whole-body inflammatory state (called a Systemic inflammatory response syndrome or SIRS caused Heart failure is a Cardiac condition that occurs when a problem with the structure or function of the Heart impairs its ability to supply

In both young and old patients, the brain may habituate to low glucose levels, with a reduction of noticeable symptoms despite neuroglycopenic impairment. In insulin-dependent diabetic patients this phenomenon is termed hypoglycemia unawareness and is a significant clinical problem when improved glycemic control is attempted. Diabetic hypoglycemia describes a low blood glucose level occurring in a person with Diabetes mellitus. Diabetes is a Chronic disease with no cure As of 2008. It is associated with an impaired Glucose cycle, altering Metabolism. Another aspect of this phenomenon occurs in type I glycogenosis, when chronic hypoglycemia before diagnosis may be better tolerated than acute hypoglycemia after treatment is underway. Glycogen storage disease (synonyms glycogenosis, dextrinosis) is any one of several inborn errors of metabolism that result from Enzyme defects

Nearly always, hypoglycemia severe enough to cause seizures or unconsciousness can be reversed without obvious harm to the brain. Cases of death or permanent neurological damage occurring with a single episode have usually involved prolonged, untreated unconsciousness, interference with breathing, severe concurrent disease, or some other type of vulnerability. Nevertheless, brain damage or death has occasionally resulted from severe hypoglycemia.

Determining the cause

Hundreds of conditions can cause hypoglycemia. Common causes by age are listed below. While many aspects of the medical history and physical examination may be informative, the two best guides to the cause of unexplained hypoglycemia are usually

  1. the circumstances
  2. a critical sample of blood obtained at the time of hypoglycemia, before it is reversed. The medical history or Anamnesis of a Patient is information gained by a Physician or other healthcare professional by asking specific questions Physical examination or clinical examination is the process by which a Health care provider investigates the body of a Patient for signs

The circumstances of hypoglycemia provide most of the clues to diagnosis

Circumstances include the age of the patient, time of day, time since last meal, previous episodes, nutritional status, physical and mental development, drugs or toxins (especially insulin or other diabetes drugs), diseases of other organ systems, family history, and response to treatment. When hypoglycemia occurs repeatedly, a record or "diary" of the spells over several months, noting the circumstances of each spell (time of day, relation to last meal, nature of last meal, response to carbohydrate, and so forth) may be useful in recognizing the nature and cause of the hypoglycemia.

An especially important aspect is whether the patient is seriously ill with another problem. Severe disease of nearly all major organ systems can cause hypoglycemia as a secondary problem. Hospitalized patients, especially in intensive care units or those prevented from eating, can suffer hypoglycemia from a variety of circumstances related to the care of their primary disease. A hospital is an institution for Health care providing treatment by specialised staff and equipment and often but not always providing for An intensive care unit (ICU critical care unit (CCU intensive therapy unit or intensive treatment unit (ITU is a specialized department used in Hypoglycemia in these circumstances is often multifactorial or even iatrogenic. The terms iatrogenesis and iatrogenic artifact refer to adverse effects or complications caused by or resulting from medical treatment or advice Once identified, these types of hypoglycemia are readily reversed and prevented, and the underlying disease becomes the primary problem.

Apart from determining nutritional status and identifying whether there is likely to be an underlying disease more serious than hypoglycemia, the physical examination of the patient is only occasionally helpful. Macrosomia in infancy usually indicates hyperinsulinism. Large for gestational age (LGA babies are those whose Birth weight lies above the 90th percentile for that Gestational age. Congenital hyperinsulinism is a medical term referring to a variety of Congenital disorders in which Hypoglycemia is caused by excessive Insulin secretion A few syndromes and metabolic diseases may be recognizable by clues such as hepatomegaly or micropenis. In Medicine and Psychology, the term syndrome refers to the association of several clinically recognizable features signs (observed by a physician Inborn errors of metabolism comprise a large class of genetic Diseases involving disorders of Metabolism. Hepatomegaly is the condition of having an enlarged Liver. It is a nonspecific medical sign having many causes which can broadly be broken down into Infection Micropenis is a medical term that describes an unusually small Penis.

Response to treatment, especially the amount of carbohydrate needed to reverse or prevent recurrence of hypoglycemia, may provide important clues as well. When 15-30 grams of sugar or starch are given by mouth, a low blood glucose will usually rise by 18-36 mg/dl (1-2 mmol/l) within 5-10 minutes, relieving hypoglycemic symptoms within 10 minutes. It may take longer to recover from severe hypoglycemia with unconsciousness or seizure even after restoration of normal blood glucose. When a person has not been unconscious, failure of carbohydrate to reverse the symptoms in 10-15 minutes increases the likelihood that hypoglycemia was not the cause of the symptoms. When severe hypoglycemia has persisted in a hospitalized patient, the amount of glucose required to maintain satisfactory blood glucose levels becomes an important clue to the underlying etiology. Glucose requirements above 10 mg/kg/minute in infants, or 6 mg/kg/minute in children and adults are strong evidence for hyperinsulinism. In this context this is referred to as the glucose infusion rate (GIR). Finally, the blood glucose response to glucagon given when the glucose is low can also help distinguish among various types of hypoglycemia. A rise of blood glucose by more than 30 mg/dl (1. 70 mmol/l) suggests insulin excess as the probable cause of the hypoglycemia.

In less obvious cases, a "critical sample" may provide the diagnosis

In the majority of children and adults with recurrent, unexplained hypoglycemia, the diagnosis may be determined by obtaining a sample of blood during hypoglycemia. If this critical sample is obtained at the time of hypoglycemia, before it is reversed, it can provide information that would otherwise require a several-thousand-dollar hospital admission and unpleasant starvation testing. A hospital is an institution for Health care providing treatment by specialised staff and equipment and often but not always providing for Perhaps the most common inadequacy of emergency department care in cases of unexplained hypoglycemia is the failure to obtain at least a basic sample before giving glucose to reverse it.

Part of the value of the critical sample may simply be the proof that the symptoms are indeed due to hypoglycemia. More often, measurement of certain hormones and metabolites at the time of hypoglycemia indicates which organs and body systems are responding appropriately and which are functioning abnormally. For example, when the blood glucose is low, hormones which raise the glucose should be rising and insulin secretion should be completely suppressed.

The following is a brief list of hormones and metabolites which may be measured in a critical sample. Not all tests are checked on every patient. A "basic version" would include insulin, cortisol, and electrolytes, with C-peptide and drug screen for adults and growth hormone in children. The value of additional specific tests depends on the most likely diagnoses for an individual patient, based on the circumstances described above. Many of these levels change within minutes, especially if glucose is given, and there is no value in measuring them after the hypoglycemia is reversed. Others, especially those lower in the list, remain abnormal even after hypoglycemia is reversed, and can be usefully measured even if a critical specimen is missed. Although interpretation in difficult cases is beyond the scope of this article, for most of the tests, the primary significance is briefly noted.

Further diagnostic steps

When suspected hypoglycemia recurs and a critical specimen has not been obtained, the diagnostic evaluation may take several paths. Insulin-like growth factor 1 (IGF-1 that was once called somatomedin C is a Polypeptide Protein Hormone similar in Molecular structure Insulin-like growth factor 2 ( IGF-2) is one of three protein Hormones that share structural similarity to Insulin. Adrenocorticotropic hormone ( ACTH or corticotropin) is a Polypeptide Hormone produced and secreted by the Pituitary gland Addison's disease (also known as chronic Adrenal insufficiency, '''hypocortisolism''' or '''hypocorticism) is a rare Endocrine disorder Alanine (abbreviated as Ala or A) is an α- Amino acid with the Chemical formula HO2CCH(NH2CH3 In Chemistry, an amino acid is a Molecule containing both Amine and Carboxyl Functional groups In Biochemistry, this Somatostatin (also known as growth hormone inhibiting hormone ( GHIH) or somatotropin release-inhibiting factor ( SRIF) is a Peptide hormone However good nutrition and prompt intake is essential.

When general health is good, the symptoms are not severe, and the person can fast normally through the night, experimentation with diet (extra snacks with fat or protein, reduced sugar) may be enough to solve the problem. If it is uncertain whether "spells" are indeed due to hypoglycemia, some physicians will recommend use of a home glucose meter to test at the time of the spells to confirm that glucoses are low. This approach may be most useful when spells are fairly frequent or the patient is confident that he or she can provoke a spell. The principal drawback of this approach is the high rate of false positive or equivocal levels due to the imprecision of the currently available meters: both physician and patient need an accurate understanding of what a meter can and cannot do to avoid frustrating and inconclusive results.

In cases of recurrent hypoglycemia with severe symptoms, the best method of excluding dangerous conditions is often a diagnostic fast. This is usually conducted in the hospital, and the duration depends on the age of the patient and response to the fast. A healthy adult can usually maintain a glucose level above 50 mg/dl (2. 8 mM) for 72 hours, a child for 36 hours, and an infant for 24 hours. The purpose of the fast is to determine whether the person can maintain his or her blood glucose as long as normal, and can respond to fasting with the appropriate metabolic changes. At the end of the fast the insulin should be nearly undetectable and ketosis should be fully established. The patient's blood glucose levels are monitored and a critical specimen is obtained if the glucose falls. Despite its unpleasantness and expense, a diagnostic fast may be the only effective way to confirm or refute a number of serious forms of hypoglycemia, especially those involving excessive insulin.

A traditional method for investigating suspected hypoglycemia is the oral glucose tolerance test, especially when prolonged to 3, 4, or 5 hours. A glucose tolerance test in medical practice is the administration of Glucose to determine how quickly it is cleared from the blood Although quite popular in the United States in the 1960s, repeated research studies have demonstrated that many healthy people will have glucose levels below 70 or 60 during a prolonged test, and that many types of significant hypoglycemia may go undetected with it. This combination of poor sensitivity and specificity has resulted in its abandonment for this purpose by physicians experienced in disorders of glucose metabolism.

Causes

There are several ways to classify hypoglycemia. The following is a list of the more common causes and factors which may contribute to hypoglycemia grouped by age, followed by some causes that are relatively age-independent. See causes of hypoglycemia for a more complete list grouped by etiology.

Hypoglycemia in newborn infants

Hypoglycemia is a common problem in critically ill or extremely low birthweight infants. If not due to maternal hyperglycemia, in most cases it is multifactorial, transient and easily supported. In a minority of cases hypoglycemia turns out to be due to significant hyperinsulinism, hypopituitarism or an inborn error of metabolism and presents more of a management challenge.

Hypoglycemia in young children

Single episodes of hypoglycemia may occur due to gastroenteritis or fasting, but recurrent episodes nearly always indicate either an inborn error of metabolism, congenital hypopituitarism, or congenital hyperinsulinism. Congenital hyperinsulinism is a medical term referring to a variety of Congenital disorders in which Hypoglycemia is caused by excessive Insulin secretion Inborn errors of metabolism comprise a large class of genetic Diseases involving disorders of Metabolism. Gastroenteritis (also known as gastro, gastric flu, and stomach flu, although unrelated to Influenza) is Inflammation of the A list of common causes:

Hypoglycemia in older children and young adults

By far, the most common cause of severe hypoglycemia in this age range is insulin injected for type 1 diabetes. In Medicine, diarrhea, also spelled diarrhoea (see spelling differences) is frequent loose or liquid Bowel movements Acute diarrhea Rotavirus is a Genus of Double-stranded RNA virus in the family Reoviridae. Ketotic hypoglycemia is a medical term used in two ways (1 broadly to refer to any circumstance in which low blood Glucose is accompanied by Ketosis, and (2 in Growth Hormone Deficiency is the medical condition of inadequate production of Growth hormone (GH and it effects on children and adults Hyperinsulinemic hypoglycemia describes the condition and effects of low blood Glucose caused by excessive Insulin. Gastric dumping syndrome, or rapid gastric emptying, happens when the lower end of the small intestine the Jejunum, fills too quickly with undigested food from the Maple syrup urine disease (MSUD also called branched-chain ketoaciduria, is an Autosomal Recessive Metabolic disorder affecting Glycogen storage disease (synonyms glycogenosis, dextrinosis) is any one of several inborn errors of metabolism that result from Enzyme defects Numerous Genetic disorders are caused by errors in Fatty acid Metabolism. Medium-chain acyl-coenzyme A dehydrogenase deficiency is a Fatty acid oxidation disorder associated with inborn errors of metabolism. Sulfonylurea (UK Sulphonylurea derivatives are a class of Antidiabetic drugs that are used in the management of Diabetes mellitus type 2 ("adult-onset" Propranolol ( INN) is a non-selective Beta blocker mainly used in the treatment of Hypertension. Diabetes mellitus type 1 (Type 1 diabetes Type I diabetes T1D T1DM IDDM juvenile diabetes is a form of Diabetes mellitus. Circumstances should provide clues fairly quickly for the new diseases causing severe hypoglycemia. All of the congenital metabolic defects, congenital forms of hyperinsulinism, and congenital hypopituitarism are likely to have already been diagnosed or are unlikely to start causing new hypoglycemia at this age. Body mass is large enough to make starvation hypoglycemia and idiopathic ketotic hypoglycemia quite uncommon. Recurrent mild hypoglycemia may fit a reactive hypoglycemia pattern, but this is also the peak age for idiopathic postprandial syndrome, and recurrent "spells" in this age group can be traced to orthostatic hypotension or hyperventilation as often as demonstrable hypoglycemia. Reactive hypoglycemia is a medical term describing recurrent episodes of symptomatic Hypoglycemia occurring 2-4 hours after a high Carbohydrate meal (or oral Idiopathic postprandial syndrome is a medical term describing a collection of symptoms popularly attributed to Hypoglycemia but without demonstrably low Glucose levels Orthostatic hypotension (also known as postural hypotension, and colloquially as head rush or a dizzy spell) is a form of Hypotension in which In Medicine, hyperventilation (or overbreathing) is the state of Breathing faster and/or deeper than necessary bringing about lightheadedness and other

Hypoglycemia in older adults

The incidence of hypoglycemia due to complex drug interactions, especially involving oral hypoglycemic agents and insulin for diabetes rises with age. Munchausen syndrome is a Psychiatric disorder in which those affected fake disease illness or psychological trauma in order to draw attention or sympathy to themselves Though much rarer, the incidence of insulin-producing tumors also rises with advancing age. Most tumors causing hypoglycemia by mechanisms other than insulin excess occur in adults.

Treatment and prevention

Management of hypoglycemia involves immediately raising the blood sugar to normal, determining the cause, and taking measures to hopefully prevent future episodes. Gastric dumping syndrome, or rapid gastric emptying, happens when the lower end of the small intestine the Jejunum, fills too quickly with undigested food from the Adrenal insufficiency is a condition in which the Adrenal glands located above the Kidneys do not produce adequate amounts of steroid hormones (chemicals produced by the

Reversing acute hypoglycemia

The blood glucose can be raised to normal within minutes by taking (or receiving) 10-20 grams of carbohydrate. Carbohydrates (from ' Hydrates of Carbon ' or saccharides ( Greek σάκχαρον meaning " Sugar " are the most It can be taken as food or drink if the person is conscious and able to swallow. This amount of carbohydrate is contained in about 3-4 ounces (100-120 ml) of orange, apple, or grape juice although fruit juices contain a higher proportion of fructose which is more slowly metabolized than pure dextrose, alternatively, about 4-5 ounces (120-150 ml) of regular (non-diet) soda may also work, as will about one slice of bread, about 4 crackers, or about 1 serving of most starchy foods. Starch is quickly digested to glucose (unless the person is taking acarbose), but adding fat or protein retards digestion. Starch, CAS # 9005-25-8 Chemical formula (C6H10O5n is a Polysaccharide Acarbose is an Anti-diabetic drug used to treat type 2 Diabetes mellitus and in some countries Prediabetes. Symptoms should begin to improve within 5 minutes, though full recovery may take 10-20 minutes. Overfeeding does not speed recovery and if the person has diabetes will simply produce hyperglycemia afterwards.

If a person is suffering such severe effects of hypoglycemia that they cannot (due to combativeness) or should not (due to seizures or unconsciousness) be given anything by mouth, medical personal such as EMTs and Paramedics, or in-hospital personnel can establish an IV and give intravenous Dextrose, concentrations varying depending on age (Infants are given 2cc/kg Dextrose 10%, Children Dextrose 25%, and Adults Dextrose 50%). Care must be taken in giving these solutions because they can be very necrotic if the IV is infiltrated. If an IV cannot be established, the patient can be given 1 to 2 milligrams of Glucagon in an intramuscular injection. Intramuscular injection is the injection of a substance directly into a Muscle. More treatment information can be found in the article diabetic hypoglycemia. Diabetic hypoglycemia describes a low blood glucose level occurring in a person with Diabetes mellitus.

One situation where starch may be less effective than glucose or sucrose is when a person is taking acarbose. Since acarbose and other alpha-glucosidase inhibitors prevents starch and other sugars from being broken down into monosaccharides that can be absorbed by the body, patients taking these medications should consume monosaccharide-containing foods such as glucose tablets, honey, or juice to reverse hypoglycemia. Alpha-glucosidase inhibitors are oral Anti-diabetic drugs used for Diabetes mellitus type 2 that work by preventing the digestion of carbohydrates (such as Starch Monosaccharides (from Greek monos: single sacchar: sugar are the most basic unit of Carbohydrates They consist of one sugar and

Prevention

The most effective means of preventing further episodes of hypoglycemia depends on the cause.

The risk of further episodes of diabetic hypoglycemia can often (but not always) be reduced by lowering the dose of insulin or other medications, or by more meticulous attention to blood sugar balance during unusual hours, higher levels of exercise, or alcohol intake.

Many of the inborn errors of metabolism require avoidance or shortening of fasting intervals, or extra carbohydrates. For the more severe disorders, such as type 1 glycogen storage disease, this may be supplied in the form of cornstarch every few hours or by continuous gastric infusion. Cornstarch, or cornflour, is the Starch of the Maize grain commonly known as Corn.

Several treatments are used for hyperinsulinemic hypoglycemia, depending on the exact form and severity. Some forms of congenital hyperinsulinism respond to diazoxide or octreotide. Diazoxide is a Potassium channel activator which causes local relaxation in Smooth muscle by increasing membrane permeability to potassium Ions Octreotide (brand name Sandostatin, Novartis Pharmaceuticals) is an octapeptide that mimics natural Somatostatin pharmacologically though it Surgical removal of the overactive part of the pancreas is curative with minimal risk when hyperinsulinism is focal or due to a benign insulin-producing tumor of the pancreas. When congenital hyperinsulinism is diffuse and refractory to medications, near-total pancreatectomy may be the treatment of last resort, but in this condition is less consistently effective and fraught with more complications.

Hypoglycemia due to hormone deficiencies such as hypopituitarism or adrenal insufficiency usually ceases when the appropriate hormone is replaced.

Hypoglycemia due to dumping syndrome and other post-surgical conditions is best dealt with by altering diet. Including fat and protein with carbohydrates may slow digestion and reduce early insulin secretion. Some forms of this respond to treatment with a glucosidase inhibitor, which slows starch digestion. Starch, CAS # 9005-25-8 Chemical formula (C6H10O5n is a Polysaccharide

Reactive hypoglycemia with demonstrably low blood glucose levels is most often a predictable nuisance which can be avoided by consuming fat and protein with carbohydrates, by adding morning or afternoon snacks, and reducing alcohol intake.

Idiopathic postprandial syndrome without demonstrably low glucose levels at the time of symptoms can be more of a management challenge. Many people find improvement by changing eating patterns (smaller meals, avoiding excessive sugar, mixed meals rather than carbohydrates by themselves), reducing intake of stimulants such as caffeine, or by making lifestyle changes to reduce stress. Caffeine is a bitter white crystalline Xanthine Alkaloid that acts as a Psychoactive Stimulant Drug and a mild Diuretic See the following section of this article.

Hypoglycemia as "folk" medicine

Hypoglycemia is also a term of contemporary folk medicine which refers to a recurrent state of symptoms of altered mood and subjective cognitive efficiency, sometimes accompanied by adrenergic symptoms, but not necessarily by measured low blood glucose. The term traditional medicine ( Indigenous medicine or folk medicine) describes medical knowledge systems which developed over centuries within various societies Symptoms are primarily those of altered mood, behavior, and mental efficiency. This condition is usually treated by dietary changes which range from simple to elaborate. Advising people on management of this condition is a significant "sub-industry" of alternative medicine. The term alternative medicine, as used in the modern western world encompasses any healing practice "that does not fall within the realm of conventional Medicine. More information about this form of "hypoglycemia", with far more elaborate dietary recommendations, is available on the internet and in health food stores. Most of these websites and books describe a conflation of reactive hypoglycemia and idiopathic postprandial syndrome but do not recognize a distinction. The value of most of their recommendations is unproven from a controlled, empirical scientific perspective.

References

  1. ^ Philip E. Cryer (1997). Hypoglycemia: pathophysiology, diagnosis, and treatment. Oxford [Oxfordshire]: Oxford University Press. ISBN 0-19-511325-X.  
  2. ^ Koh TH, Eyre JA, Aynsley-Green A (1988). "Neonatal hypoglycaemia--the controversy regarding definition". Arch. Dis. Child. 63 (11): 1386–8. PMID 3202648.  
  3. ^ Cornblath M, Schwartz R, Aynsley-Green A, Lloyd JK (1990). "Hypoglycemia in infancy: the need for a rational definition. A Ciba Foundation discussion meeting". Pediatrics 85 (5): 834–7. PMID 2330247.  
  4. ^ Cornblath M, Hawdon JM, Williams AF, Aynsley-Green A, Ward-Platt MP, Schwartz R, Kalhan SC (2000). "Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds". Pediatrics 105 (5): 1141–5. doi:10.1542/peds.105.5.1141. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 10790476.  
  5. ^ a b Tustison WA, Bowen AJ, Crampton JH (1966). "Clinical interpretation of plasma glucose values". Diabetes 15 (11): 775–7. PMID 5924610.  
  6. ^ a b c [edited by] John Bernard Henry (1979). Clinical diagnosis and management by laboratory methods. Philadelphia: Saunders. ISBN 0-7216-4639-5.  
  7. ^ Clarke WL, Cox D, Gonder-Frederick LA, Carter W, Pohl SL (1987). "Evaluating clinical accuracy of systems for self-monitoring of blood glucose". Diabetes Care 10 (5): 622–8. doi:10.2337/diacare.10.5.622. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 3677983.  
  8. ^ Gama R, Anderson NR, Marks V (2000). "'Glucose meter hypoglycaemia': often a non-disease". Ann. Clin. Biochem. 37 ( Pt 5): 731–2. doi:10.1258/0004563001899825. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 11026531.  
  9. ^ de Pasqua A, Mattock MB, Phillips R, Keen H (1984). "Errors in blood glucose determination". Lancet 2 (8412): 1165. PMID 6150231.  
  10. ^ Horwitz DL (1989). "Factitious and artifactual hypoglycemia". Endocrinol. Metab. Clin. North Am. 18 (1): 203–10. PMID 2645127.  
  11. ^ Samuel Meites, editor-in-chief; contributing editors, Gregory J. Buffone. . . [et al. ] (1989). Pediatric clinical chemistry: reference (normal) values. Washington, D. C: AACC Press. ISBN 0-915274-47-7.  
  12. ^ edited by Allen I. Arieff, Robert C. Griggs (1992). Metabolic brain dysfunction in systemic disorders. Boston: Little, Brown. ISBN 0-316-05067-9.  
  13. ^ The Hypoglycemic states - Hypoglycemia. The Hypoglycemic states. Armenian Medical Network (2007).

See also

External links

Hyperglycemia, hyperglycaemia, or high blood sugar is a condition in which an excessive amount of Glucose circulates in the Blood plasma Glucose (Glc a Monosaccharide (or simple Sugar) also known as grape sugar, is an important Carbohydrate in Biology. Diabetes mellitus (ˌdaɪəˈbiːtiːz or /ˌdaɪəˈbiːtəs/ /məˈlaɪtəs/ or /ˈmɛlətəs/ often referred to simply as diabetes ( Ancient Greek: grc Diabetic coma is a Medical emergency in which a person with Diabetes mellitus is Comatose (unconscious because of one of the acute complications Diabetic hypoglycemia describes a low blood glucose level occurring in a person with Diabetes mellitus. Hyperinsulinemic hypoglycemia describes the condition and effects of low blood Glucose caused by excessive Insulin. Congenital hyperinsulinism is a medical term referring to a variety of Congenital disorders in which Hypoglycemia is caused by excessive Insulin secretion Idiopathic Hypoglycemia is literally a medical condition in which the Glucose level in the Blood ( Blood glucose) is abnormally low Idiopathic postprandial syndrome is a medical term describing a collection of symptoms popularly attributed to Hypoglycemia but without demonstrably low Glucose levels Reactive hypoglycemia is a medical term describing recurrent episodes of symptomatic Hypoglycemia occurring 2-4 hours after a high Carbohydrate meal (or oral

Dictionary

hypoglycemia

-noun

  1. (pathology) A low level of blood glucose.
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