A 43 year old woman is brought to the emergency department 1 hour after a stranger stole her purse. She is agaitated and extremely upset. She is 163 cm (5 ft 4 in) tall and weight 91 kg (200 lb); BMI is 34 kg/m2. Physical examination show no other abnormalities. Her blood glucose concentration is increased.

1. Clinical Case
Group consisting of Fabian Nelson,
Maximous Philobos, Sonny Brar and
Ajay Singh

2. Clincial Case Intro
• A 43 year old woman is brought to the
emergency department 1 hour after a stranger
stole her purse. She is agaitated and extremely
upset. She is 163 cm (5 ft 4 in) tall and weight
91 kg (200 lb); BMI is 34 kg/m2. Physical
examination show no other abnormalities. Her
blood glucose concentration is increased.

3. Which of the following is the most
likely explanation for her symptoms?
•
•
•
•
•
B-cell hypersecretion
Cushing disease
Glucagon-secreting adenoma
Pancreatitis
Normal stress hormone response

4. Beta-Cell hypersecretion
Beta- Cell hypersecretion is an excess secretion
of insulin from the beta cells of the pancreas. A
tumor of the inslet beta cells will cause an
overproduction of insulin. Causing
hypoglycemia, there is a very low incidence of
this condition.

5. Symptoms
1.
2.
3.
4.
5.
Anxiety and sweating.
Body tremors
Elevated body temperature
Disorientation
The patient can go into Insulin shock due to
brain hypoglycemia.

6. Treatment
In patients with indolent, slow-growing
metastatic islet cell tumors, the best therapy
may be careful observation, and no treatment
until palliation is required. Chemotherapy, and
in some instances surgery is necessary.

7. Prognosis
They are uncommon cancers with about 1,000
new cases per year in the United States. They
account for 3% to 5% of pancreatic malignancies
and overall have a better prognosis than the
more common pancreatic exocrine tumors. Fiveyear survival is about 55% when the tumors are
localized and resected but only about 15% when
the tumors are not resectable. Overall 5-year
survival rate is about 42%.

8. Cushing Disease Definition
• AKA Cushing Syndrome or Hypercortisolism
• Occurs when your body is exposed to high
levels of cortisol for an extended time.
• Most common cause is use of oral
corticosteroid medication.
• Condition can also occur when body makes to
much cortisol.

9. Cushing Disease Definition (Cont.)
• Hallmark signs:
• Fatty hump between shoulders
• Rounded face
• Pink or purple stretch marks on skin
• Can also result in:
• High blood pressure
• Bone loss
• Diabetes on occasion

10. Cushing Disease Definition (Cont.)
• Treatments for disease can return body’s
cortisol levels to normal
• Noticeably improve the symptoms
• Also, the earlier treatment begins, the better
chance are for recovery.

11. Common signs and symptoms
• Involves progressive and skin changes that are
as follows:
• Weight gain and fatty tissue deposits, particularly
around the midsection and upper back, in the face
(moon face), and between the shoulders (buffalo
hump)
• Pink or purple stretch marks (striae) on the skin of the
abdomen, thighs, breasts and arms
• Thinning, fragile skin that bruises easily
• Slow healing of cuts, insect bites and infections
• Acne

12. Common signs and symptoms (Cont.)
• Women with Cushing Disease:
• Thicker or more visible body and facial hair (hirsutism)
• Irregular or absent menstrual periods
• Men with Cushing Disease:
• Decreased libido
• Decreased fertility
• Erectile dysfunction

13. Common signs and symptoms (Cont.)
• Additional signs and
symptoms:
• Fatigue
• Muscle weakness
• Depression, anxiety
and irritability
• Loss of emotional
control
• Cognitive difficulties
• New or worsened high
blood pressure
• Glucose intolerance
that may lead to
diabetes
• Headache
• Bone loss, leading to
fractures over time

14. Causes of Cushing Disease
• Results from excess levels of cortisol in body
• Endocrine system consists of glands that regulate
processes throughout our bodies
• The glands are:
•
•
•
•
•
•
•
Adrenal glands
Pituitary gland
Thyroid gland
Parathyroid gland
Pancreas
Ovaries
Testicles

15. Causes of Cushing Disease (Cont.)
• Adrenal gland secretes cortisol and many
other hormones
• Cortisol has a variety of roles in our body:
• helps regulate your blood pressure and keeps your
cardiovascular system functioning normally
• helps your body respond to stress and regulates the
way you convert (metabolize) proteins, carbohydrates
and fats in your diet into usable energy

16. Corticosteroids role
• Disease can develop from cause that comes
from outside our body (exogenous Cushing
Disease)
• High does of corticosteriods taken over long
periods can result in the disease
• These meds like prednisone have the same
effects the cortisol produced by our body

17. Corticosteroids role (Cont.)
• They may be prescribed by a doctor to treat:
• Inflammatory diseases (Ex: Rheumatoid Arthritis)
• Lupus and Asthma
• Prevent the rejection of transplanted organ
• Develop disease from injectable
corticosteroids:
• Repeated injections for joint pain, bursitis and back
pain

18. Corticosteroids role (Cont.)
• Certain inhaled steroid medicines (taken for
Asthma)
• Steroid skin creams used for skin maladies like
eczema
• Important to note that this is less likely to cause
Cushing’s Disease but in same general category of drugs
• But the disease might occur in some individuals if drugs
are taken in high doses

19. Our Body’s own Overproduction
• The disease can result from our body’s own
overproduction of cortisol (endogenous
Cushing Disease):
•
•
•
•
Pituitary gland tumor (pituitary adenoma)
Ectopic ACTH-secreting tumor
Primary adrenal gland disease
Familial Cushing Disease

20. Complications
• Do not receive immediate treatment, other
complications may occur:
• Bone loss (osteoporosis), which can result in unusual bone
fractures, such as rib fractures and fractures of the bones in
the feet
• High blood pressure (hypertension)
• Diabetes
• Frequent or unusual infections
• Loss of muscle mass and strength
• If cause is a pituitary tumor, this can lead to other
problems such as disrupting the production of
other hormones that the pituitary controls

21. Glaucagon-secreting adenoma
A glucagonoma is a tumor that secretes
glucagon, a hormone normally produced in the
pancreas and responsible for raising blood sugar
(glucose) levels. Glucagonomas are almost
entirely found in the pancreas, arising from the
alpha-2 cells of the gland, and about 80% of
these tumors are malignant (cancerous). The
tumor can cause elevated blood glucose levels
known as glucagonoma syndrome but this is not
present in every case.

22. What is the occurrence of Glucagonoma?
Overall glucagonomas are rare neuroendocrine
tumors. It only accounts for about 1% of all
neuroendocrine tumors. The incidence of
glucagonomas is estimated to be about 1 in 20
million people. The high risk age group is
between 40 to 70 years with the average age of
onset being 55 years. Women seem to be more
likely than men to develop glucagonomas.

23. Symptoms
•
•
•
•
•
Unintentional weight loss
Inflamed mouth
Diarrhea
Increased appetite
Anemia

24. Causes
The causes of a glucagonoma are unknown.
Patients may have a family history of glucagonoma.
The condition is also associated with multiple
endocrine neoplasia (MEN) type I which is a known
risk factor. A glucagonoma is a neuroendocrine
tumor that is localized to the pancreas in almost all
cases. Secretion of glucagon arises either as a result
of the mass apply pressure on the glucagonsecreting alpha-2 pancreatic cells or the tumor cells
itself producing and secreting glucagon
independently.

25. Diagnosis
A diagnosis of glucagonoma is often missed as
these tumors are rare. The presence of the 4 D’s
– diabetes, dermatitis (necrolytic migratory
erythema), deep vein thrombosis and
depression – should raise the concern about a
glucagonoma. The confirmation of the diagnosis
involves several investigations such as Blood Test
and Scans.

26. Treatment
• Octreotide is a drug that inhibits the secretion of glucagon. It can
help relieve some of the symptoms associated with a glucagonoma
but may worsen diabetes.
• Chemotherapy is reserved for cases where surgery is not possible
or the cancer has already spread (metastasis). However,
chemotherapy has a very limited use in the treatment of
glucagonomas.
• Surgery is ideal in that the tumor can be removed and all symptoms
will resolve thereafter. Due to the high chance of spread and often
late diagnosis, some of the healthy tissue surrounding the tumor
and regional lymph nodes are resected as well

27. Prognosis
The survival rate for a glucagonoma is poor. The
tumor grows very slowly so there are cases
where patients live for 15 years or more after
diagnosis. The 5 year survival rate is about 85%
after surgery where the tumor was localized to
the pancreas and successfully removed.

28. Pancreatitis
• Pancreatitis is inflammation in the pancreas
• The pancreas is a long, flat, mixed exocrine
and endocrine gland that sits tucked behind
the stomach in the upper abdomen.
• The pancreas produces enzymes that help
digestion and hormones that help regulate the
way the body processes sugar (glucose).

29. Pancreatic Enzymes
• Pancreas secretes three important enzymes:
– Protease: digestion of proteins
– Lipase: hydrolysis of triglycerides
– Amylase: hydrolysis of starch into maltose (a
glucose-glucose disaccharide)
• Some of which are secreted in active and
inactive forms

30. What happens in Pancreatitis?
• Pancreatitis occurs when digestive enzymes
produced in the pancreas become activated
while inside the pancreas, causing damage to
the organ.
• The enzymes responsible are proteases:
– Trypsin
– Chymotrypsin

31. Trypsin and Chymotrypsin
• Both enzymes are synthesized in their inactive forms:
– Trypsinogen
– Chymotrypsinogen
• In normal digestion, these Enzymes are synthesized and
packaged into secretory vesicles which is a way for the
cells to safely handle these enzymes
• secretory vesicles also contain a trypsin inhibitor which
serves as an additional safeguard should some of the
trypsinogen be activated to trypsin; following
exocytosis this inhibitor is diluted out and becomes
ineffective to allow for proper function in small
Intestine

32. Trypsin and Chymotrypsin (Cont.)
• Once trypsinogen and chymotrypsinogen are
released into the lumen of the small intestine,
they must be converted into their active forms
in order to digest proteins.
• Trypsinogen is activated by the enzyme
enterokinase.
• Once trypsin is formed it activates
chymotrypsinogen, as well as additional
molecules of trypsinogen.

33. What Goes Wrong?
• In pancreatitis, the enzymes become activated
while still in the pancreas.
• Causing the enzymes to irritate the cells of the
pancreas, creating inflammation and the signs
and symptoms associated with pancreatitis.

34. Causes
•
•
•
•
•
•
•
•
•
Alcoholism
Gallstones
Abdominal surgery
Medications
Smoking
Cystic fibrosis
Family history
High blood calcium levels (hypercalcemia)
High levels of parathyroid hormone in the blood
(hyperparathyroidism)
• High triglyceride levels in the blood (hypertriglyceridemia)
• Pancreatic cancer

35. Forms of Pancreatitis
• Acute:
– Upper abdominal pain
– Abdominal pain that radiates to the back
– Abdominal pain that feels worse after eating
– Nausea
– Vomiting
– Tenderness when touching the abdomen

36. Forms of Pancreatitis (Cont.)
• Chronic:
– Upper abdominal pain
– Indigestion
– Losing weight without trying
– Oily, smelly stools (steatorrhea)

37. Complications
•
•
•
•
•
•
•
Breathing problems
Diabetes
Infection
Kidney failure
Malnutrition
Pancreatic cancer
Pancreatic cysts

38. Normal Stress Hormone Response
• When you encounter a perceived threat
(robbery in this case)
• The hypothalamus, a tiny region at the base of
the brain, sets off an alarm system in the body.
• Stimulating adrenal glands, located above the
kidneys, to release a surge of hormones,

39. Hormones
• Some of the hormones release:
– Adrenaline: increases heart rate, elevates blood
pressure and boosts energy supplies
– Cortisol: primary stress hormone, increases sugars
(glucose) in the bloodstream, enhances brain's use
of glucose, and increases the availability of
substances that repair tissues

40. Other Effects of Cortisol
• Alters immune system responses
• Suppresses the digestive system, the
reproductive system and growth processes
• Communicates with regions of your brain that
control mood, motivation, and fear.

41. When the Natural Stress Response
Goes Haywire!
• The body's stress-response system is usually
self-limiting
• However over activation of the stress-response
system causes overexposure to adrenaline,
cortisol, and other stress hormones
• Can disrupt almost all the body's processes
causing severe long term health problems

42. Long Term Complications
•
•
•
•
•
•
•
Anxiety
Depression
Digestive problems
Heart disease
Sleep problems
Weight gain
Memory and concentration impairment

43. In Conclusion
• Collectively, we feel the appropriate choice to
the case would be the normal stress hormone
response.
• Increased cortisol answers why her blood
glucose would be elevated, and the anger and
agitation would cause the increase. Her BMI
is high but that is not the reason for her stay.

46. Normal Stress Hormone Response
The normal stress hormone response is
initially very debilitating but recovery will
occur when the threat is removed.
If the threat itself is not removed the patient
may manifest PTSD (post-traumatic stress
disorder), which may manifest shortly-after
the inciting event or weeks to months or even
years later.
PTSD effects 1 in every 3 individuals with a
traumatic experience.

47. Treatment
• If the patient manifests PTSD, treatment
would depend on the symptoms and how
soon they occurred after the inciting event.
• Options of treatment may be waiting to see if
symptoms improve without treatment,
psychological therapy such as cognitive
behavioural therapy (CBT) and/ or eye
movement desensitisation and reprocessing
(EDMR), and antidepresseant medication
such as paroxetine or mirtazapine.

48. 6 Phases of Cognitive Behavioral
Therapy
1.
2.
3.
4.
5.
6.
Assessment or psychological assessment
Reconceptualization
Skills acquisition
Skills consolidation and application training.
Generalization and maintenance
Post-treatment assessment follow-up

50. Paroxetine
• Belongs to selective-serotonin reuptake
inhibitors
• Used to treat mental depression, obsessivecompulsive disorder, panic disorder,
generalized anxiety disorder, social anxiety
disorder (aka social phobia), premenstrual
dysphoric disorder, and PTSD
• US brand name paxil, paxil CR and pexeva

51. Mirtazapine
• Belongs to tetracyclic antidepressants
• Works on CNS to make certain chemicals in
the brain stronger
• Used to treat depression
• US brand names are remeron and remeron
soltab

52. THE END

53. Just kidding

54. Sources
• Bowen, R. "Exocrine Secretions of the Pancreas." Exocrine
Secretions of the Pancreas. Colorado State University, 5
July 2006. Web. 13 Nov. 2013.
<http://www.vivo.colostate.edu/hbooks/pathphys/digestion/
pancreas/exocrine.html>.
• Staff, Mayo Clinic. "Chronic Stress Puts Your Health at
Risk." Mayo Clinic. Mayo Foundation for Medical
Education and Research, 11 July 2013. Web. 13 Nov. 2013.
<http://www.mayoclinic.com/health/stress/SR00001>.
• Staff, Mayo Clinic. "Pancreatitis." Mayo Clinic. Mayo
Foundation for Medical Education and Research, 15 Jan.
2011. Web. 13 Nov. 2013.
<http://www.mayoclinic.com/health/pancreatitis/DS00371>
.

55. Sources (Cont.)
• Staff, Mayo Clinic. ”Cushing Syndrome." Mayo
Clinic. Mayo Foundation for Medical Education
and Research, 28 Mar. 2013. Web. 5 Nov. 2013.
<http://www.mayoclinic.com/health/cushingssyndrome/DS00470>.
• Marcus, Saul ND. “Adrenal Exhaustion and
Chronic Fatigue: The most common reason
people feel tired all the time.” Naturopathic
Wellness. 2013. Web. 17 Nov 2013.

56. • Tammy. “Dealing with stress.”
Tammysyoga.co.uk. 13 Jun 2013. Web. 17 Nov
2013. “Post-traumatic stress disorder.” NHS
Choices. 24 Sep 2013. Web. 17 Nov 2013.
• Wikipedia. “Cognitive behavioral therapy.”
Wikimedia Foundation, Inc. 4 Nov 2013. Web.
17 Nov 2013.

57. • “Mirtazapine (Oral Route).” Mayo
Foundation for Medical Education and
Research. 13 Jul 2013. Web. 17 Nov 2013.
• “Paroxetine (Oral Route).” Mayo Foundation
for Medical Education and Research. 1 Aug
2013. Web. 17 Nov 2013.