HYPOGLYCEMIA (hypoglycemia; grech, hypo-+ glykys sweet + haima blood) — reduced concentration of glucose in blood to 70 mg of % during the definition by Hagedorn's method — Janszen.
Functional G., observable and is most widespread among almost healthy people (apprx. 70% of all cases).
Alimentary G. can arise at healthy people after reception of a large amount of digestible carbohydrates and is caused by bystry absorption of glucose from intestines. At the same time in the beginning considerable usually develops hyperglycemia (see), G. which is replaced in 3 — 5 hours of sharp G. V these cases is caused by compensatory increase in an inkretion of insulin in response to a hyperglycemia (alimentary, or paradoxical, a hyper dysinsulinism). It can be observed at hard and long muscular work when there is an unindemnifiable considerable consumption of carbohydrates as energy sources. Sometimes G. arises at women in the period of a lactation, apparently, as a result of sharp acceleration of transport of glucose from blood in cells of a mammary gland.
So-called neurogenic, or reactive, G. arising owing to an imbalance of century of N of page usually develops at astenik and emotionally unbalanced people, especially later physical. and intellectual tension on an empty stomach, and also is a consequence hyper dysinsulinism (see).
The expressed G. can be a symptom of various diseases and patol, states. It can be observed at patients in the postoperative period after a gastroenterostomy and a partial or full resection of a stomach. Most often G. is a consequence of diseases of a pancreas when there is a hyperplasia of beta cells of islets of Langerhans and a large amount of insulin is produced (hyper dysinsulinism); it is observed at an insuloma, adenoma and a pancreatic cancer.
Can arise at severe defeat of a parenchyma of a liver (poisoning with phosphorus, chloroform, acute yellow dystrophy of a liver, cirrhosis, etc.), at glycogenoses (in particular, at a disease to Awnless wheat) owing to genetically determined decrease of the activity or lack of the enzyme of glyukozo-6-phosphatase completing processes of a gluconeogenesis and glyukozoobrazovaniye of a glycogen of a liver.
At diseases of kidneys G. is caused by elimination from blood of a significant amount of glucose owing to decrease for it a renal threshold; often is followed glycosuria (see).
It is observed at diseases when the inkretion antagonistic to insulin of hormones decreases: at hypofunction of bark of adrenal glands (an addisonov a disease, tumors of adrenal glands, etc.), hypofunctions and atrophies of a front share of a hypophysis (Simmonds's disease), hypofunctions of the thyroid gland caused by primary decrease in an inkretion of thyritropic hormone of a hypophysis.
The special form G. results from overdose of the insulin entered with the therapeutic purpose (e.g., at diabetes).
Spontaneous G. name decrease in content of glucose in blood at not endocrine diseases that is connected with sensitization of the insulyarny device to usual irritants and a thicket it is observed after meal, carbohydrate-rich. Carry the neurogenic G. observed at diseases of a nervous system to spontaneous G. (encephalitis, a general paralysis, etc.) and at mental diseases (a cyclotymia, hron, alcoholism), brain injuries.
Patofiziologichesky mechanism in most cases G. is connected with carbohydrate (glucosic) starvation of fabrics, especially a brain, the caused hyper dysinsulinism or decrease in an inkretion of hormones antagonists. The acceleration of transport of glucose stimulated by insulin from blood in fabric which is slowing down influence of insulin on processes of a gluconeogenesis and a glyukozoobrazovaniye in a liver and kidneys with the subsequent delay of intake of glucose from these bodies in a blood channel is a proximate cause of G., and at G. of a renal origin — acceleration of release of glucose from blood in urine. At decrease in content of glucose lower than 50 — 40 mg of % develop in blood disturbances of activity of c. the N of page in connection with insufficient intake of glucose in nervous cells, is broken absorption of oxygen by them and there is a hypoxia of a brain (see. Hypoxia ). Believe that at G. the reserve of a glycogen in a brain is exhausted quickly and that at long G. there are irreversible destructive changes. In gray and white matter of a brain are noted a hyperemia, staz, hemorrhages, swelling of fabrics, vacuolation of kernels and cells.
A clinical picture
At decrease in concentration of glucose in blood to 70 mg of % weakness, feeling of hunger, a shiver in extremities can appear. Expressed a wedge, G.'s symptoms appear at decrease in content of glucose in blood lower than 50 — 40 mg of %.
The hypoglycemic syndrome can be divided into four stages (according to Conn, etc.). Intermediate stages without their sharp differentiation are possible.
The first stage is shown by easy fatigue at physical. and intellectual tension, little reduced ABP. Pallor of integuments, cold sweat are characteristic of the second stage, the tremor of hands, sensation of fear, a heart consciousness is sometimes observed. At the third stage obtusion of sensitivity joins the listed symptoms. The subjective state during this period quite often reminds a condition of a drunkenness: «bravado», disappearance of fear of the approaching attack, failure to eat sugar, etc.; sometimes there are hallucinations. In the fourth stage the shiver passing into convulsions like epilepsy amplifies; at absence to lay down. the help of the patient gradually falls into coma (see. Coma , hypoglycemic).
G.'s symptomatology at diseases of a nervous system is defined by hl. obr. precipitancy and depth of crisis (speed and a limit of falling of concentration of sugar in blood). After feeling of sharp weakness, feeling of exhaustion, an acute hunger, profuse perspiration, etc. there are somatoneurologic, vegetodystonic (synpaticotonic in the beginning and vagotonic at a late stage) symptoms of disorder of mental activity arising in process of increase of devocalization from its easy degree dr a deep sopor.
At early stages of G. when destructive changes are unsharply expressed, a condition of patients during the interparoxysmal periods, on Bleylera (M. to Bleuler), clinically is defined as an endocrine psychosyndrome. Its main signs consist in sharply expressed lability of mood with its disproportionate fluctuations, existence of the general asthenic background as reflection of less sharp fluctuations of concentration of the sugar in blood remaining and in the interparoxysmal period at the lower level of norm (apprx. 70 mg of % during the definition on Hagedorna — to Janszen).
At a heavy current of G. maniacal, delirious, katatonopodobny, hallucinatory paranoid episodes, motive concern, grimacing, sucking and other stereotypic movements, violent laughters and crying, horeopodobny and atetoidny hyperkinesias, the torsion spasm and epileptic seizures can be observed, it is frequent with an opisthotonos. Frustration of mentality can be various or be shown some one, napr, typical epileptic, an attack that often conducts to diagnostic mistakes. G.'s attacks can be long and often repeat that inevitably leads to a serious organic illness of c. N of page from the outcome in weak-mindedness.
Clinically polymorphism of a hypoglycemic syndrome is caused not only by variability of symptoms and considerable range of manifestations of frustration of mentality, but also a wavy current, and it defines big lability and temporary reversibility of symptoms. The sequence of mental disorders such is that in the beginning autokinesias and the highest functions of mental activity fall apart; then there are patol, productive mental symptoms which with increase of devocalization give way to the hyperkinetic excitement which is replaced by an attack of the tonic and clonic spasms which are coming to the end with a coma.
Diagnosis is based on the accounting of features of a current of attacks, duration and an atipichnost of convulsive attacks and data of studying of character of sugar curves (see. Carbohydrates , methods of definition). At the same time it is necessary to establish the reason which caused G.
Before specification of the reason of G. each patient during an attack needs the urgent help; the earlier she is rendered, the it is easier to stop an attack. The patient needs to give 100 g of sugar, at spasms and a coma — intravenously to pour in glucose (40 ml of 50% of solution). At alimentary G., and also at a disease to Awnless wheat administration of carbohydrates can worsen situation of the patient, in these cases adrenaline (1 ml of 0,1% of solution) which will quickly mobilize glucose of a liver in blood is shown. Radical treatment consists in elimination of the reason which caused G.
the Forecast depends on the reason which caused. Frequent repetition of attacks of G. without the correct and timely treatment can lead to a serious organic illness of c. N of page from the outcome in weak-mindedness. Death at a long and deep hypoglycemic attack comes seldom since the spasms caused by G. cause splitting of a glycogen of muscles, formation of surplus milk to - you and synthesis from it in a liver of the glucose coming to blood; other protective mechanism is the reactive hyperadrenalemia.
A hypoglycemia at children
the Hypoglycemia at children — the kliniko-metabolic syndrome observed at many hereditary and acquired diseases. G.'s emergence, frequent in comparison with adults, at children depends from anatomo-fiziol, features of a children's organism, imperfection of metabolic adaptation and more frequent in comparison with adults of manifestation of hereditary defects.
At children the following main types G. are observed:
1. With a hyper dysinsulinism: a) spontaneous G. (at adenoma and a hypertrophy of beta cells of a pancreas, at the newborns who were born from mothers sick with a diabetes mellitus, idiopathic); b) the induced G. (caused by a L-leucine, tryptophane, extra pancreatic tumors, salicylates, administration of glucose to children with an inadequate insulinosekretion — at obesity, a prediabetes).
2. Without hyper dysinsulinism: group of hereditary enzymopathies (aglikogenoz, glycogenoses I, III, IV, VII types), neonatal G., a hypoglycemia at insufficiency of adrenal glands, a glucagon, somatotropic hormone, at a syndrome Mac-Carry, intolerantnost to fructose, a galactose, G. at intoxication (alcoholic, medicamentous), ketogenic G.
Naiboley are frequent at children the following Forms.
Neonatal hypoglycemia. This concept is entered in 1929 by Van-S. van Creveld who noted that the level of glucose in blood at newborn children is usually lower, than at children of advanced age. Cornblath with sotr. (1959) described 8 newborns in coma, spasms with cyanosis and an apnoea at which for the second day of life deep G. Prichina of neonatal G. came to light it is not known yet, disturbance of regulation of a glycemia is supposed. Neonatal symptomatic G. is observed at the full-term newborns weighing less than 2500, at younger of twins (is more often than boys). At. the birth a condition of children normal, but within several hours or days the tremor, irritability, cyanosis, an apnoea, sometimes spasms appear. Content of glucose y is usually lower than blood 20 mg of % and is frequent — lower than 10 mg of %. This state is not eliminated with intravenous administration of 10% of solution of glucose, can be liquidated only by administration of the concentrated solution of glucose or AKTG, however in most cases disappears spontaneously. Neonatal G.'s forecast adverse: to a half of children further lag behind in intellectual development, the cataract, an atrophy of an optic nerve develop, visual acuity gradually decreases.
Hypoglycemia of newborns owing to cooling it is shown, in addition to a hypothermia and the low content of glucose in blood, by an erythema and small puffiness of extremities, periorbital hypostasis, weak shout which usually begin during the warming of the child. Hemorrhages in lungs, accession of an infection, dysfunction of kidneys can be heavy complications. Treatment — intravenous administration of glucose, according to indications — antibiotics. The forecast is favorable, at the correct leaving the child recovers.
Hypoglycemia with a ketosis (synonym ketogenic G.) it is more often observed on the first year of life (but sometimes up to 6 years) and characterized by G.'s attacks with acetonuria, an acetonemia after the short periods of starvation. Intervals between G.'s attacks are various, attacks can spontaneously disappear for indefinite time. The reason is unknown. The diagnosis can be established by special provocative test: in the beginning the patient is 3 — 5 days on a high-carbohydrate diet, then, after a night break, it is given a low-calorie ketogenic diet; children with ketogenic G. react to this test of acetonurias, a hypoglycemia, glyukagonrezistentny low level of sugar and increase in concentration of not esterified fatty acids in blood within a day. Treatment — a diet with reduction of content of fats, hypodispersion within a day carbohydrates, an easy dinner before going to bed; during G.'s attacks — intravenous injection of glucose. The forecast is favorable, at a rational diet of the phenomenon of a ketosis pass.
Idiopathic spontaneous hypoglycemia it is observed more often in the early childhood, but the long period can proceed. The reasons are unknown. G.'s combination to anomaly of an organogeny of sight is possible; sometimes family cases meet. A symptomatic treatment, a dietotherapy it is ineffective. At serious conditions renders effect a subtotal pancreatectomy. Forecast adverse.
L-leucine hypoglycemia it is described by Kokrin (Cochrane, 1956). Patofiziol, the mechanism, by means of to-rogo L - the leu - tsin causes G., is not established, but it is known that administration of some amino acids to persons, sensitive to them, causes a hyper dysinsulinism. Genetic aspects of this form G. are not studied yet. Pathognomonic a wedge, there are no signs, but the index of suspicion shall be very high if at children after meal with the high content of protein there comes drowsiness, pallor or there are spasms. In the first weeks of life of the child these symptoms need to be differentiated with those at a hyperphosphatemia and a hypocalcemia which can develop if the child is given in a large number cow's milk. Leucine G.'s diagnosis is established by the test of portability of a leucine: the leucine in a dose of 150 mg on 1 kg of body weight is allowed to accept inside; in 15 — 45 min. at the children sensitive to a leucine, the content of glucose in blood decreases twice, being combined with increase in content of insulin; Treatment — a diet with the minimum protein content (it is not enough a leucine) and high content of carbohydrates. Forecast: though spontaneous remissions are also observed, repeated attacks of G. can cause serious lag in intellectual and physical. development.
Hypoglycemia at an insulinoma is more characteristic of children of advanced age and develops after physical. loadings, starvations; G.'s attacks can be very heavy. The diagnosis of insular adenoma can be suspected at children with long hypoglycemic states, resistant to therapy. Treatment surgical.
Hypoglycemia at extra pancreatic the tumors having a mesodermal origin it can be connected as with direct products a tumor of insulinopodobny substances, and with a secondary giperinsulinemiya owing to stimulation of the insulyarny device neoplazirovanny fabric. An opportunity and the accelerated metabolism of tryptophane, defiant, as well as a leucine, G. at children is not excluded. The method of treatment is defined by the oncologist.
Hypoglycemia at insufficiency somatotropic hormone (a full or partial hypopituitarism — see. Hypopituitarism ) at insufficiency of adrenal glands, a thyroid gland, deficit of a glucagon or insufficiency of food is secondary and it is connected with a role of hormones of these glands in regulation of content of glucose.
Hypoglycemia at a disease of «maple syrup» it is connected with disturbance of absorption of glucose and a giperleytsinemiya, inherent to this disease (see. Dekarboksilaznaya insufficiency ).
Hypoglycemia at a drunkenness at children's age proceeds hard, emergency treatment in the form of adequate administration of glucose, cardiacs is necessary.
Hypoglycemia owing to toxic action of medicines or hypersensitivity to them arises at reception of salicylates, an atsetogeksamida, at overdose of insulin, etc. The forecast is favorable, G. is liquidated at drug withdrawal.
Bibliography: Genes S. G. Hypoglycemia, Hypoglycemic symptom complex., 1970, bibliogr.; r about l of l of m and N And. Clinical endocrinology and its physiological bases, the lane with English, M., 1969; Diabetes, under the editorship of R. Williams, the lane with English, page 560, M., 1964; Both l and N V. S. Mekhanizm of effect of insulin, Vestn. USSR Academy of Medical Sciences, No. 8, page 3, 1969; The Multivolume guide to pathological physiology, under the editorship of H. N. Sirotinina, t. 4, page 280, M., 1966; In arta L. Hyperglycaemia and hypo-glycaemia in childhood, Acta paediat., (Uppsala), v. 13, p. 69, 1972; D e r o t M * et Goury-LaffontM. Les maladies de la nutrition, P., 1970; G a r d n e r L. I. Endocrine and genetic diseases of childhood, p. 798, Philadelphia — L., 1969; Labhart A. Klinik der inneren Sekretion, B. u. a., 1971; Oakley W. G., the Hand of D. A. a. T an at 1 o r K. W. Diabetes and its management, Oxford, 1975, bibliogr.; Pathogenesis of diabetes mellitus, ed. by E. Cesari a. R. Luft, Stockholm, 1970
B. S. Ilyin; Yu. A. Knyazev (ped.), I. M. Savich (psikhiat.).