Insulinomas

An insulinoma is a type of functional neuroendocrine tumor that manifests with hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia due to autologous secretion of insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin. It more commonly presents as a solitary benign tumor but can sometimes be associated with MEN type 1 (MEN1). Patients present with fasting hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia, which may manifest as episodes of diaphoresis, palpitations, tremor, and confusion. Insulinoma is usually diagnosed with high insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin, C peptide, and proinsulin levels despite the patient’s hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia. Localization of the insulinoma is done with imaging. Surgical removal of the insulinoma is the treatment of choice, but medical therapy may be utilized to prevent hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia in those who cannot undergo surgery.

Last update:

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Table of Contents

Share this concept:

Share on facebook
Share on twitter
Share on linkedin
Share on reddit
Share on email
Share on whatsapp

Definition and Epidemiology

Definition

Insulinomas are pancreatic neuroendocrine tumors Pancreatic Neuroendocrine Tumors Pancreatic neuroendocrine tumors (PanNETs) arise from the endocrine pancreas (islet cells) and represent 2%-5% of primary pancreatic neoplasms; the other 95%-98% of pancreatic neoplasms are from the exocrine pancreas. The majority of PanNETs are nonfunctional (50%-75%), while others that are functional may be benign or malignant. Pancreatic Neuroendocrine Tumors (PanNETs) that are derived from beta cells and secrete insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin.

Epidemiology

  • Incidence: approximately 1–4 cases per million people per year
  • No sex or ethnic predisposition
  • All age groups
  • In 5%–10% of cases, insulinomas are malignant.
  • 6% of cases associated with MEN type 1 (MEN1) syndrome (associated with parathyroid, pituitary, and pancreatic tumors)

Related videos

Pathophysiology

Normal insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin physiology

Synthesis:

  • Proinsulin:
    • Stored in secretory granules
    • Composed of three peptide chains: A, B, and C
    • Cleaved in the Golgi apparatus → insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin and C peptide
  • Insulin: 
    • Consists of 2 chains connected by 2 disulfide linkages: A and B chains
    • Released from pancreatic beta cells

Regulation:

  • Stimulated by:
    • Meal constituents:
      • Glucose
      • Amino acids
      • Free fatty acids Fatty acids Fatty acids are integral building blocks of lipids, and can be classified as unsaturated or saturated based on the presence/absence of carbon-carbon double bonds within their nonpolar chains. Fatty Acids and Lipids
    • Enteric hormones Hormones Hormones are messenger molecules that are synthesized in one part of the body and move through the bloodstream to exert specific regulatory effects on another part of the body. Hormones play critical roles in coordinating cellular activities throughout the body in response to the constant changes in both the internal and external environments. Hormones: Overview:
      • Glucagon-like peptide 1 (GLP-1)
      • Gastric inhibitory polypeptide (GIP, also known as glucose-dependent insulinotropic polypeptide)
      • Cholecystokinin
    • Neural agonists:
      • Beta-adrenergic receptor stimulation via norepinephrine
      • Acetylcholine 
      • Vasoactive intestinal polypeptide (VIP)
  • Inhibited by:
    • Alpha-adrenergic receptor stimulation via norepinephrine
    • Somatostatin 

Release:

  1. Glucose enters beta cells.
  2. ATP production from glucose metabolism
  3. Closure of ATP-sensitive K-channels
  4. Beta cell depolarization
  5. Calcium (Ca) influx due to voltage-gated Ca-channel opening 
  6. Insulin and C-peptide exocytosis

Function:

  • ↑ Glucose uptake in skeletal muscle and adipose tissue Adipose tissue Adipose tissue is a specialized type of connective tissue that has both structural and highly complex metabolic functions, including energy storage, glucose homeostasis, and a multitude of endocrine capabilities. There are three types of adipose tissue, white adipose tissue, brown adipose tissue, and beige or "brite" adipose tissue, which is a transitional form. Adipose Tissue via glucose transporter type 4 (GLUT4, an insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin-dependent transporter)
  • ↑ Glycogen synthesis
  • ↑ Protein synthesis and ↓ proteolysis
  • ↑ Triglyceride synthesis and ↓ lipolysis
  • Gluconeogenesis Gluconeogenesis Gluconeogenesis is the process of making glucose from noncarbohydrate precursors. This metabolic pathway is more than just a reversal of glycolysis. Gluconeogenesis provides the body with glucose not obtained from food, such as during a fasting period. The production of glucose is critical for organs and cells that cannot use fat for fuel. Gluconeogenesis and glycogenolysis 
  • ↓ Glucagon release
The conversion of proinsulin to insulin

The conversion of proinsulin to insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin:
The A and B chains remain connected by disulfide bridges, while the C peptide is cleaved.

Image by Lecturio.

Pathophysiology of insulinomas

  • Insulinomas are functional neuroendocrine tumors derived from pancreatic islet cells.
  • Results in autonomously secreted insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin even when plasma glucose concentration is low
  • Failure to suppress insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin plus inhibited glucose synthesis → hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia
  • A catecholamine response occurs → symptoms
  • ↓ Cerebral glucose → neuroglycopenic symptoms

Clinical Presentation

Patients generally present with fasting hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia, which may manifest in episodes of sympathetic stimulation and/or central nervous system Nervous system The nervous system is a small and complex system that consists of an intricate network of neural cells (or neurons) and even more glial cells (for support and insulation). It is divided according to its anatomical components as well as its functional characteristics. The brain and spinal cord are referred to as the central nervous system, and the branches of nerves from these structures are referred to as the peripheral nervous system. General Structure of the Nervous System disturbances.

  • Symptoms of sympathetic activation:
    • Tremor
    • Pallor
    • Anxiety
    • Diaphoresis
    • Palpitations
  • Neuroglycopenic symptoms:
    • Confusion
    • Blurred vision
    • Ataxia
    • Seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures
    • Coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma

Diagnosis

Whipple triad

A collection of criteria that signal that a patient’s symptoms are a result of hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia, which will be present in patients with an insulinoma:

  • ↓ Serum glucose
  • Symptoms of hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia
  • Resolution of symptoms after glucose administration

Laboratory evaluation

The following laboratory values can assist in the diagnosis. These may be performed during a 48- or 72-hour fasting evaluation:

  • ↓ Serum glucose level
  • Inappropriately ↑ serum insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin
  • ↑ C-peptide
  • ↑ Proinsulin
  • Negative test for sulfonylureas

MEN1 genetic testing may be performed for: 

  • Young patients
  • Family or personal history of other endocrinopathies 

Imaging

The following imaging modalities are useful for localizing the insulinoma and preoperative planning:

  • CT or MRI of the abdomen:
    • Can detect 70%–85% of insulinomas
    • Findings:
      • Small, solid mass
      • Enhances with contrast
  • Nuclear imaging Nuclear Imaging Nuclear imaging is the radiologic examination using radiopharmaceuticals, which are radioactive substances taken up by specific types of cells. Nuclear medicine is more concerned with the functional and molecular aspects of the organ or pathology being investigated rather than the structure. Nuclear Imaging: used if conventional imaging is unremarkable
  • EGD with endoscopic ultrasound of the pancreas Pancreas The pancreas lies mostly posterior to the stomach and extends across the posterior abdominal wall from the duodenum on the right to the spleen on the left. This organ has both exocrine and endocrine tissue. Pancreas:
    • Invasive
    • May be utilized if CT and MRI are negative but a strong suspicion remains
Radiographic and surgical findings insulinoma

Radiographic and surgical findings for an insulinoma:
A: A large insulinoma of the pancreatic tail was detected with combined CT and nuclear medicine imaging.
B: The gross appearance of the insulinoma after it was resected laparoscopically

Image: “Preoperative Glucagon-like peptide-1 receptor imaging reduces surgical trauma and pancreatic tissue loss in insulinoma patients: a report of three cases” by Wenning AS, Kirchner P, Antwi K, Fani M, Wild D, Christ E, Gloor B. License: CC BY 4.0

Management

Surgical resection

Removal of the insulinoma is the treatment of choice and provides a favorable cure rate.

For resectable tumors (depending on tumor location and number): 

  • Carries the most favorable prognosis
  • Enucleation of solitary tumors
  • Partial distal pancreatectomy 
  • Total pancreatectomy
  • Whipple procedure 

For metastatic disease to the liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver:

  • Resection
  • Cryotherapy
  • Radiofrequency ablation 
  • Embolization 

Medical therapy

Medications to prevent symptomatic hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia may be used if the insulinoma is unresectable or the patient is a poor surgical candidate.

  • Diazoxide:
    • Potassium channel activator
    • Inhibits insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin secretion
  • Octreotide: 
    • Somatostatin analog
    • 2nd-line treatment after diazoxide
    • Can inhibit secretion of:
      • Insulin
      • Glucagon
      • Gastrin

Differential Diagnosis

  • Factitious hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia: may result from exogenous self-administration of insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin. Factitious hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia is often seen with healthcare workers who present with symptoms of hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia. Unlike insulinomas, a laboratory evaluation will reveal low C-peptide and proinsulin levels despite high insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin levels. Management includes correcting hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia and psychiatric therapy.
  • Sulfonylurea toxicity: may occur in patients who are not eating or have renal impairment. Patients will present with hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia. Unlike with insulinomas, serum sulfonylurea testing will be positive. Management includes withdrawal of the causative agent and treatment for hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia.
  • Persistent hyperinsulinemic hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia of infancy (PHHI): most common cause of persistent hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia in neonates and infants, caused by mutations involving different proteins leading to insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin release dysregulation. A laboratory evaluation will show inappropriately detectable levels of insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin and C-peptide, low beta-hydroxybutyrate Beta-hydroxybutyrate Butyric acid substituted in the beta or 3 position. It is one of the ketone bodies produced in the liver. Fatty Acid Metabolism and free fatty acids Fatty acids Fatty acids are integral building blocks of lipids, and can be classified as unsaturated or saturated based on the presence/absence of carbon-carbon double bonds within their nonpolar chains. Fatty Acids and Lipids, and a glycemic response to glucagon. Genetic testing is often performed. Management may include diazoxide, octreotide, or surgery.
  • Insulin autoimmune hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia: occurs in patients who have autoantibodies directed to endogenous insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin or the insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin receptor, which results in hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia. Detection of antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins to insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin will provide the diagnosis. This condition is managed with small, frequent meals; steroids; and, in severe cases, plasmapheresis.

References

  1. Vella, A. (2021). Insulinoma. In Mulder, J.E. (Ed.). UpToDate. Retrieved April 13, 2021, from https://www.uptodate.com/contents/insulinoma
  2. Service, FJ, et al. (1991). Functioning insulinoma—Incidence, recurrence, and long-term survival of patients: A 60-year study. Mayo Clinic Proceedings. 66(7), 711–19. https://pubmed.ncbi.nlm.nih.gov/1677058/
  3. Kavlie, H, White, TT. (1972). Pancreatic islet beta cell tumors and hyperplasia: Experience in 14 Seattle hospitals. Annals of Surgery. 175(3), 326–35. https://pubmed.ncbi.nlm.nih.gov/4342703/
  4. Lupsa, BC, et al. (2009). Autoimmune forms of hypoglycemia. Medicine. 88(3), 141–53. https://pubmed.ncbi.nlm.nih.gov/19440117/
  5. Nguyen, M. (2021). Insulinoma. MSD Manual Professional Version. Retrieved April 18, 2021, from https://www.msdmanuals.com/professional/gastrointestinal-disorders/tumors-of-the-gastrointestinal-tract/insulinoma
  6. Zhuo, F, and Anastasopoulou, C. (2020). Insulinoma. StatPearls. Retrieved April 18, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK544299/
  7. Ali, ZA. (2020). Insulinoma. In Radhakrishnan, N. (Ed.). Medscape. Retrieved April 18, 2021, from https://emedicine.medscape.com/article/283039-overview

USMLE™ is a joint program of the Federation of State Medical Boards (FSMB®) and National Board of Medical Examiners (NBME®). MCAT is a registered trademark of the Association of American Medical Colleges (AAMC). NCLEX®, NCLEX-RN®, and NCLEX-PN® are registered trademarks of the National Council of State Boards of Nursing, Inc (NCSBN®). None of the trademark holders are endorsed by nor affiliated with Lecturio.

Study on the Go

Lecturio Medical complements your studies with evidence-based learning strategies, video lectures, quiz questions, and more – all combined in one easy-to-use resource.

Learn even more with Lecturio:

Complement your med school studies with Lecturio’s all-in-one study companion, delivered with evidence-based learning strategies.

User Reviews

0.0

()

¡Hola!

Esta página está disponible en Español.

🍪 Lecturio is using cookies to improve your user experience. By continuing use of our service you agree upon our Data Privacy Statement.

Details