pancreatic endocrine tumors are classified , according to the symptomatology , in secreting and nonsecreting tumors .
the nonsecreting tumors ( silent , in hormonal terms ) represent about 50% of the total ; they are followed by insulinomas - 25% and gastrinomas - 15% .
it may be associated with other endocrine glands tumors in the multiple endocrine neoplasia type i ( men i ) ( parathyroid , pituitary , endocrine pancreas ) .
the islet cell tumors are the most common cause of hypoglycemia resulting from endogenous hyperinsulinism .
the median age at diagnosis is about 47 years , except in insulinoma patients with men 1 , in whom the median age is the mid-20 s .
a 61-years old man known with hypertension and alcoholic steatohepatitis , presented on 26/03/2013 for syncopes , tonic - clonic seizures , sweating , anxiety .
alcohol consumption had been stopped 2 months before the onset of the symptoms , according to the patient and his relatives statements . in the patient medical history we found an emergency admission on 20/02/2013 for psychomotor agitation , episodes of loss of consciousness with tonic - clonic seizures , delirium of mixed etiology ( alcohol and hypoglycemia ) , tremor of the upper limbs , sweating , disorientation in time and space , important hypoprosexia , fixing and evocation hypoamnesia , insomnia .
blood tests evidenced 41 mg / dl hypoglicemia , hyperkaliemia , twice the normal values of lactate dehydrogenase ( ldh ) .
the cranial computed tomography ( ct ) did not reveal any damage except an old ischemic millimetric lesion and a degree of atrophy .
the patient was admitted to the diabetes , nutritional and metabolic diseases clinic for suspected insulinoma .
the abdominal ct revealed no pathological changes in the abdominal organs , no lymph node changes . due to his agitation , seizures , and delirium ,
the symptoms were interpreted as alcohol withdrawal and he was transferred to the department of psychiatry . during hospitalization
the blood glucose fasting levels were found again between 30 and 50 mg / dl .
the neurologist interpreted the old ischemic lesion shown on the ct as possibly due to hypoxic damage caused by severe hypoglycemia .
the patient was discharged with the diagnosis of complicated withdrawal seizures , chronic alcohol dependence , history of disabling ischemic stroke in the left carotid territory , with recommendation for hospitalization in a medical clinic .
the following were determined : the c peptide , insulinemia and glycated hemoglobin , which were normal and did not support the diagnosis of insulinoma .
, hypoglycemia was attributed to the alcohol consumption and the patient was released on 03/04/2013 . after a month , on 26/03/2013 , the patient came back for persistent symptoms .
blood tests showed 39 to 59 mg / dl glucose levels and mixed dyslipidemia , carbohydrate antigen ( ca)19 - 9 was normal , the other analyses were normal .
we decided to repeat the abdominal magnetic resonance imaging ( mri ) with contrast , and we discovered a 21 mm hypervascular tumor of the pancreatic uncinate process , suggesting , as first hypothesis , an endocrine tumor and peripancreatic millimetre lymph nodes .
we transferred the patient to the surgery department , where the uncinate process tumor was excised and peripancreatic lymph nodes were biopsied . the histopathological appearance ( fig .
3 ) was positive in 56% of tumor cells ( nuclear expression ) , findings that were supporting the diagnosis of neuroendocrine tumor .
based on the result of the histopathological examinations , corroborated with the imaging and intraoperative exploration , the tumor stage was as pt3n0mx .
the  rule of 10  states that 10% are multiple , 10% are malignant ,
insulinomas are associated with men 1 in 5% of patients and it is estimated that 21% of patients with men1 develop insulinomas . the incidence is 310 cases per million people per year . once surgically removed , the insulinomas occurring in this autosomal dominant syndrome have a higher risk of relapse . long - term survival of patients with insulinoma is generally excellent ; it is considered that approximately 9095% of insulinomas have benign histological behavior , so healing with dissaperance of symptomatology after complete resection is the rule .
recurrences were observed in 5.4% of cases in a series of 120 patients with benign insulinomas , over a period of 417 years . in these cases
long - term survival is possible in malignant insulinomas , especially in cases strictly localized to the pancreas and with good response to adjuvant chemotherapy ; median disease - free survival after curative resection is estimated at 5 years .
the diagnosis of insulinoma often comes from a hunch , from the impossibility of highlighting the cause of repeated hypoglycemia in an apparently healthy patient . but for diagnostic certainty , patient follow - up and repeated analysis are necessary .
proper management for timely treatment of a patient with insulinoma involves complex medical teamwork consisting of physicians from various specialties : endocrinology , internal medicine , surgery , pathology , medical imaging , oncology and , like in our case , psychiatry .
 insulinoma is a rare pancreatic islet cell tumor , the most common cause of hypoglycemia related to endogenous hyperinsulinism . 
 we present the case of an adult patient with pancreatic insulinoma . 
 the patient presented to our clinic after prior hospitalizations in diabetes and psychiatry hospital units for repeated episodes of loss of consciousness , sweating and tonic - clonic seizures . 
 early detection of the cause is important for prompt initiation of therapy and to reduce symptoms . 
 we describe our diagnostic and therapeutic strategies with references to previously published reports . 
Introduction
Case report
Discution
Conclusion