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He D, Gong H, Pan J, Zhu F, Jiang X, Su H. Recurrent Non-islet Cell Tumor Hypoglycemia Secondary to Hepatocellular Carcinoma: Case Report and Literature Review. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:752-758. [PMID: 37798922 DOI: 10.1055/a-2170-1691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
RATIONALE Non-islet cell tumor hypoglycemia (NICTH) is a paraneoplastic syndrome caused by tumors other than insulinoma that is primarily due to excessive production of insulin-like growth factor-II (IGF-II). The prevalence of NICTH is likely underestimated because of a lack of clinical recognition. PATIENT CONCERNS A 41-year-old male with massive malignant liver tumors presented with recurrent severe hypoglycemia, weight loss, and liver cirrhosis. DIAGNOSIS NICTH related to IGF-II produced by hepatocellular carcinoma was diagnosed based on clinical symptoms, biochemical tests, and elevated IGF-II/IGF-I ratio. INTERVENTION Initial treatment with intravenous glucose and parenteral nutrition showed limited efficacy. Glucocorticoids and recombinant human growth hormone led to progressive improvement in blood glucose levels. OUTCOME Due to extensive tumor burden and liver failure, surgical resection was not feasible, and the patient ultimately succumbed to refractory hypoglycemia and passed away in two weeks. LESSONS Early recognition and diagnosis of NICTH are crucial in patients with recurrent hypoglycemia and large tumors. Surgical resection is the preferred treatment option, but supportive care and pharmacological interventions, such as glucocorticoids and growth hormone, can help manage refractory hypoglycemia. Further research is needed to explore novel treatment options, including anti-IGF-I and -IGF-II neutralizing antibodies.
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Affiliation(s)
- Dan He
- Department of Gastroenterology, Wenzhou Central Hospital, Wenzhou, China
| | - Hongpeng Gong
- Department of Gastroenterology, Wenzhou Central Hospital, Wenzhou, China
| | - Jie Pan
- Department of Gastroenterology, Wenzhou Central Hospital, Wenzhou, China
| | - Fangchao Zhu
- Department of Gastroenterology, Wenzhou Central Hospital, Wenzhou, China
| | - Xiaofen Jiang
- Department of Gastroenterology, Wenzhou Central Hospital, Wenzhou, China
| | - Huang Su
- Department of Gastroenterology, Wenzhou Central Hospital, Wenzhou, China
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Quiroz-Aldave JE, Gamarra-Osorio ER, Durand-Vásquez MDC, Rafael-Robles LDP, Gonzáles-Yovera JG, Quispe-Flores MA, Concepción-Urteaga LA, Román-González A, Paz-Ibarra J, Concepción-Zavaleta MJ. From liver to hormones: The endocrine consequences of cirrhosis. World J Gastroenterol 2024; 30:1073-1095. [PMID: 38577191 PMCID: PMC10989500 DOI: 10.3748/wjg.v30.i9.1073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 01/02/2024] [Accepted: 02/06/2024] [Indexed: 03/06/2024] Open
Abstract
Hepatocrinology explores the intricate relationship between liver function and the endocrine system. Chronic liver diseases such as liver cirrhosis can cause endocrine disorders due to toxin accumulation and protein synthesis disruption. Despite its importance, assessing endocrine issues in cirrhotic patients is frequently neglected. This article provides a comprehensive review of the epidemiology, pathophysiology, diagnosis, and treatment of endocrine disturbances in liver cirrhosis. The review was conducted using the PubMed/Medline, EMBASE, and Scielo databases, encompassing 172 articles. Liver cirrhosis is associated with endocrine disturbances, including diabetes, hypoglycemia, sarcopenia, thyroid dysfunction, hypogonadotropic hypogonadism, bone disease, adrenal insufficiency, growth hormone dysfunction, and secondary hyperaldosteronism. The optimal tools for diagnosing diabetes and detecting hypoglycemia are the oral glucose tolerance test and continuous glucose monitoring system, respectively. Sarcopenia can be assessed through imaging and functional tests, while other endocrine disorders are evaluated using hormonal assays and imaging studies. Treatment options include metformin, glucagon-like peptide-1 analogs, sodium-glucose co-transporter-2 inhibitors, and insulin, which are effective and safe for diabetes control. Established standards are followed for managing hypoglycemia, and hormone replacement therapy is often necessary for other endocrine dysfunctions. Liver transplantation can address some of these problems.
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Affiliation(s)
| | | | | | | | | | | | | | - Alejandro Román-González
- Department of Endocrinology, Hospital Universitario de San Vicente Fundación, Medellin 050010, Colombia
- Internal Medicine, Universidad de Antioquia, Medellín 050010, Colombia
| | - José Paz-Ibarra
- School of Medicine, Universidad Nacional Mayor de San Marcos, Lima 15081, Peru
- Department of Endocrinology, Hospital Nacional Edgardo Rebagliati Martins, Lima 15072, Peru
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Gan L, Zhu X, Gao Y, Zhong M, Liao S, Huang G, Yan Y. A review on nondiabetic hypoglycemia from various causes: Case series report. Medicine (Baltimore) 2023; 102:e36273. [PMID: 38013348 PMCID: PMC10681503 DOI: 10.1097/md.0000000000036273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/02/2023] [Indexed: 11/29/2023] Open
Abstract
RATIONALE Hypoglycemia is common in patients with glucose regulation disorders and related diabetic treatments but is rare in nondiabetic patients. Severe hypoglycemia can cause harm to patients' cognition, consciousness, central nervous system, cardiovascular and cerebrovascular system, and even death. However, the most fundamental way to control hypoglycemia is to identify the cause and deal with the primary disease. This article introduces 3 cases of nondiabetic hypoglycemia with different causes, aiming to improve our understanding of nondiabetic hypoglycemia and improve the ability of early diagnosis and differential diagnosis. PATIENT CONCERNS Case 1 is a 19-year-old female with a history of recurrent coma, and magnetic resonance imaging and endoscopic ultrasound of the pancreas suggest insulinoma. Case 2 is a 74-year-old male with a history of viral hepatitis, and computerized tomography shows multiple nodules in the liver, which is diagnosed as liver cancer. Case 3 is a 39-year-old female with a history of taking methimazole, who tested positive for insulin antibodies, and was diagnosed with insulin autoimmune syndrome. DIAGNOSIS All 3 patients were diagnosed with nondiabetic hypoglycemia, but the causes varied, and included insulinoma, non-islet cell tumor-induced hypoglycemia, and insulin autoimmune syndrome. INTERVENTIONS Case 1 underwent pancreatic tail resection; case 2 refused anti-tumor treatment and received glucose injections for palliative treatment only; and case 3 stopped taking methimazole. OUTCOMES After surgery, the blood sugar in case 1 returned to normal, and the blood sugar in case 2 was maintained at about 6.0 mmol/L. The symptoms of hypoglycemia gradually improved in case 3 after stopping the medication. LESSONS Non-diabetic hypoglycemia requires further examination to clarify the cause, and the correct differential diagnosis can provide timely and effective treatment, improving the patient's prognosis.
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Affiliation(s)
- Lulu Gan
- Department of Endocrinology, Xiaogan Hospital Affiliated to Wuhan University of Science and Technology, The Central Hospital of Xiaogan, Xiaogan, Hubei, China
- Medical College of Wuhan University of Science and Technology, Wuhan, China
| | - Xuan Zhu
- Medical College of Wuhan University of Science and Technology, Wuhan, China
| | - Yue Gao
- Medical College of Wuhan University of Science and Technology, Wuhan, China
| | - Mingyao Zhong
- Medical College of Wuhan University of Science and Technology, Wuhan, China
| | - Shibo Liao
- Department of Endocrinology, Xiaogan Hospital Affiliated to Wuhan University of Science and Technology, The Central Hospital of Xiaogan, Xiaogan, Hubei, China
| | - Gao Huang
- Department of Endocrinology, Xiaogan Hospital Affiliated to Wuhan University of Science and Technology, The Central Hospital of Xiaogan, Xiaogan, Hubei, China
| | - Yimin Yan
- Department of Endocrinology, Xiaogan Hospital Affiliated to Wuhan University of Science and Technology, The Central Hospital of Xiaogan, Xiaogan, Hubei, China
- Medical College of Wuhan University of Science and Technology, Wuhan, China
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Wahid Satar SNA, Norhayati MN, Yaacob LH. Recurrent hypoglycemia in a patient with hepatocellular carcinoma. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2023. [DOI: 10.29333/ejgm/12903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Hypoglycemia is a common complication of diabetes mellitus. Patients may present with any kind of symptoms, either autonomic or neuroglycopenic. Here, we report a case of a 70-year-old man with type 2 diabetes mellitus with a newly diagnosed hepatocellular carcinoma presenting with recurrent episodes of hypoglycemia. The insulin treatment was withheld initially. However, the patient's diabetic control worsened after starting treatment for his hepatocellular carcinoma. Hence, the insulin treatment was resumed. This case highlighted the challenge in balancing the management of hypoglycaemia and poor diabetic control in a patient who has diabetes mellitus and hepatocellular carcinoma. Primary care practitioners need to have high clinical suspicion to monitor these patients to prevent hypoglycemia and manage them accordingly.
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Affiliation(s)
- Siti Nor Ain Wahid Satar
- Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, MALAYSIA
| | - Mohd Noor Norhayati
- Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, MALAYSIA
| | - Lili Husniati Yaacob
- Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, MALAYSIA
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Hwang S, Choi Y, Lee BH, Choi J, Kim JH, Yoo H. Pediatric hepatocellular carcinoma associated with Niemann-Pick disease type C: Case report and literature review. JIMD Rep 2023; 64:27-34. [PMID: 36636588 PMCID: PMC9830012 DOI: 10.1002/jmd2.12344] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 10/04/2022] [Accepted: 10/07/2022] [Indexed: 11/11/2022] Open
Abstract
Niemann-Pick disease type C (NPC) is a rare, autosomal recessive, lysosomal storage disease, resulting from mutations in the cholesterol trafficking proteins NPC1 or NPC2, which is characterized by progressive neurodegeneration and hepatic dysfunction. The hepatic involvement in NPC is usually neonatal cholestasis and hepatosplenomegaly. Only a few cases of severe hepatic complications were reported including acute liver failure, cirrhosis, and hepatocellular carcinoma (HCC). We described the case of a 6-year-old male with NPC with HCC. He had a history of neonatal cholestasis and motor delay. At the age of 6 months, he was diagnosed with NPC, which was confirmed by the detection of a compound heterozygous NPC1 mutation (p.C113Y/p.A927V). He presented recurrent hypoglycemia and abdominal distension. An ultrasound, computed tomography scan, and biopsy revealed that he had a stage IV HCC with pulmonary metastasis. With the literature review and this case, HCC can be a rare fatal comorbid condition in patients with NPC, particularly infantile-onset, male patients with a relatively long disease history, necessitating appropriate HCC surveillance.
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Affiliation(s)
- Soojin Hwang
- Department of Pediatrics, Asan Medical Center Children's HospitalUniversity of Ulsan College of MedicineSeoulRepublic of Korea
| | - Yunha Choi
- Department of Pediatrics, Asan Medical Center Children's HospitalUniversity of Ulsan College of MedicineSeoulRepublic of Korea
| | - Beom Hee Lee
- Department of Pediatrics, Asan Medical Center Children's HospitalUniversity of Ulsan College of MedicineSeoulRepublic of Korea
- Medical Genetics Center, Asan Medical Center Children's HospitalUniversity of Ulsan College of MedicineSeoulRepublic of Korea
| | - Jin‐Ho Choi
- Department of Pediatrics, Asan Medical Center Children's HospitalUniversity of Ulsan College of MedicineSeoulRepublic of Korea
| | - Ja Hye Kim
- Department of Pediatrics, Asan Medical Center Children's HospitalUniversity of Ulsan College of MedicineSeoulRepublic of Korea
| | - Han‐Wook Yoo
- Department of Pediatrics, Asan Medical Center Children's HospitalUniversity of Ulsan College of MedicineSeoulRepublic of Korea
- Medical Genetics Center, Asan Medical Center Children's HospitalUniversity of Ulsan College of MedicineSeoulRepublic of Korea
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Abstract
INTRODUCTION Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide, and a significant proportion (20-40%) of patients with HCC develop paraneoplastic syndromes (PNS). Despite this, there is a paucity of clinical evidence regarding PNS in HCC. AREAS COVERED A systematic search was performed to identify relevant case studies regarding PNS in HCC. Another search was conducted to identify studies that evaluated the impact of PNS on survival outcomes in HCC. Since there are currently no international guidelines for PNS in HCC, this review aims to provide comprehensive summaries and recommendations of PNS in HCC, including the pathophysiology, clinical features, diagnostic approach, and management, so that clinicians remain guided in caring for HCC patients with PNS. In general, PNS are associated with poorer survival outcomes and negative prognostic markers of HCC. EXPERT OPINION The presence of PNS has a significant influence on survival rates and clinical outcomes of patients with HCC. They contribute to significant morbidity, influencing patients' quality of life and fitness for curative and palliative therapies. Therefore, it is paramount for PNS to be integrated into routine investigations after diagnosing HCC to guide further management and prognostication of the disease.
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Affiliation(s)
- Yuki Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Cheong Wei Terence Huey
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Hepato-Pancreatico-Biliary Surgery, Department of Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Vishalkumar Girishchandra Shelat
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Hepato-Pancreatico-Biliary Surgery, Department of Surgery, Tan Tock Seng Hospital, Singapore, Singapore
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Xiang J, Wang K, Tang N. PCK1 dysregulation in cancer: Metabolic reprogramming, oncogenic activation, and therapeutic opportunities. Genes Dis 2022; 10:101-112. [PMID: 37013052 PMCID: PMC10066343 DOI: 10.1016/j.gendis.2022.02.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/13/2022] [Accepted: 02/15/2022] [Indexed: 02/07/2023] Open
Abstract
The last few decades have witnessed an advancement in our understanding of multiple cancer cell pathways related to metabolic reprogramming. One of the most important cancer hallmarks, including aerobic glycolysis (the Warburg effect), the central carbon pathway, and multiple-branch metabolic pathway remodeling, enables tumor growth, progression, and metastasis. Phosphoenolpyruvate carboxykinase 1 (PCK1), a key rate-limiting enzyme in gluconeogenesis, catalyzes the conversion of oxaloacetate to phosphoenolpyruvate. PCK1 expression in gluconeogenic tissues is tightly regulated during fasting. In tumor cells, PCK1 is regulated in a cell-autonomous manner rather than by hormones or nutrients in the extracellular environment. Interestingly, PCK1 has an anti-oncogenic role in gluconeogenic organs (the liver and kidneys), but a tumor-promoting role in cancers arising from non-gluconeogenic organs. Recent studies have revealed that PCK1 has metabolic and non-metabolic roles in multiple signaling networks linking metabolic and oncogenic pathways. Aberrant PCK1 expression results in the activation of oncogenic pathways, accompanied by metabolic reprogramming, to maintain tumorigenesis. In this review, we summarize the mechanisms underlying PCK1 expression and regulation, and clarify the crosstalk between aberrant PCK1 expression, metabolic rewiring, and signaling pathway activation. In addition, we highlight the clinical relevance of PCK1 and its value as a putative cancer therapeutic target.
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Kalra S, Bhattacharya S, Rawal P. Hepatocrinology. Med Sci (Basel) 2021; 9:medsci9020039. [PMID: 34205986 PMCID: PMC8293374 DOI: 10.3390/medsci9020039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/10/2021] [Accepted: 05/24/2021] [Indexed: 11/17/2022] Open
Abstract
Hepatocrinology is defined as a bidirectional, complex relationship between hepatic physiology and endocrine function, hepatic disease and endocrine dysfunction, hepatotropic drugs and endocrine function, and endocrine drugs and hepatic health. The scope of hepatocrinology includes conditions of varied etiology (metabolic, infectious, autoimmune, and invasive) that we term as hepato-endocrine syndromes. This perspective shares the definition, concept, and scope of hepatocrinology and shares insight related to this aspect of medicine. It is hoped that this communication will encourage further attention and research in this critical field.
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Affiliation(s)
- Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal 132001, India
- Correspondence: ; Tel.: +09-(19)-896048555
| | | | - Pawan Rawal
- Department of Gastroenterology, Artemis Hospital, Gurgaon 122002, India;
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Gómez Torres KM, Molina Villalba C, Estévez Escobar M. Lenvatinib in severe hypoglycemia associated with hepatocelular carcinoma. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2021; 113:799. [PMID: 33947193 DOI: 10.17235/reed.2021.8016/2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We present the case of a 24-year-old man with multicentric hepatocellular carcinoma over HBV cirrhosis treated with Sorafenib and Tenofovir. He comes to our center for repeated episodes of symptomatic hypoglycemia that cannot be managed with standard measures. After ruling out different possibilities, the suspicion of hypoglycemia due to a non-islet cell tumor was finally confirmed. Given the impossibility of a curative treatment due to a reduced functional reserve, Sorafenib was changed to Lenvatinib, thereby improving glycemic control.
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Regino CA, López-Montoya V, López-Urbano F, Alvarez JC, Roman-Gonzalez A. Paraneoplastic Hypoglycemia in Hepatocarcinoma: Case Report and Literature Review. Cureus 2020; 12:e12013. [PMID: 33457120 PMCID: PMC7797408 DOI: 10.7759/cureus.12013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Hypoglycemia is a common medical emergency in the context of insulin treatment in diabetic patients and oral hypoglycemic agents such as sulfonylureas. In anecdotal cases, hypoglycemia is associated with non-islet cell tumor-induced hypoglycemia (NICTH). In hepatocellular carcinoma (HCC), it has been reported in 4-27% of patients, and it is associated with poor prognosis. We present a case report of a patient with hypoglycemia associated with HCC secondary to chronic hepatitis B virus infection without response to treatment with glucagon, steroids, octreotide, and embolizations, who required parenteral nutrition at home. Even though hypoglycemia associated with HCC is a recognized entity, there is not sufficient evidence in its treatment and prevention. The article aims to review the literature on prevention and therapeutic options.
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Affiliation(s)
| | | | | | - Jose C Alvarez
- Internal Medicine, University of Antioquia, Medellín, COL
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