A 42-year-old man has recurrent episodes of confusion relieved by eating. During a supervised 72-hour fast he develops neuroglycopenic symptoms with plasma glucose 38 mg/dL, insulin 9 microU/mL, C-peptide elevated, and negative sulfonylurea screen. CT pancreas is normal. The best next step is:

• A Diaxoxide therapy lifelong
• B Exploratory laparotomy with blind distal pancreatectomy
• C Intraoperative ultrasound after laparoscopic exploration of the pancreas ✓
• D Total pancreatectomy

Explanation

The biochemical picture confirms endogenous hyperinsulinaemic hypoglycaemia consistent with insulinoma. Because these tumours are often subcentimetre and missed on cross-sectional imaging, the standard approach is surgical exploration with intraoperative ultrasound, which detects over 90 percent of lesions and guides enucleation. Blind distal pancreatectomy misses nonpalpable tumours, diazoxide is for unresectable or medically unfit patients, and total pancreatectomy is never indicated for a benign solitary lesion.

Reference: Sabiston Textbook of Surgery, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.