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Whipple's triad is a collection of three signs (called Whipple's criteria) that suggests that a patient's symptoms result from hypoglycaemia that may indicate insulinoma. The essential conditions are symptoms of hypoglycaemia, low blood plasma
glucose Glucose is a sugar with the Chemical formula#Molecular formula, molecular formula , which is often abbreviated as Glc. It is overall the most abundant monosaccharide, a subcategory of carbohydrates. It is mainly made by plants and most algae d ...
concentration, and relief of symptoms when plasma glucose concentration is increased. It was first described by the pancreatic surgeon Allen Whipple, who aimed to establish criteria for exploratory pancreatic surgery to look for insulinoma.


Definition

Whipple's triad is stated in various versions. The essential conditions are: # Symptoms known or likely to be caused by hypoglycaemia, especially after fasting or intense exercise. These symptoms include tremor, tachycardia, anxiety, dizziness, and loss of consciousness. # A low blood plasma
glucose Glucose is a sugar with the Chemical formula#Molecular formula, molecular formula , which is often abbreviated as Glc. It is overall the most abundant monosaccharide, a subcategory of carbohydrates. It is mainly made by plants and most algae d ...
concentration measured at the time of the symptoms. This may be measured as a blood plasma glucose concentration of less than 550 milligrams per litre. # Relief of symptoms when glucose level is increased. The use and significance of the criteria have evolved over the last century as understanding of the many forms of hypoglycaemia has increased and diagnostic tests and imaging procedures have improved. Whipple's criteria are no longer used to justify surgical exploration for an insulinoma, but to separate "true hypoglycaemia" (in which a low glucose can be demonstrated) from a variety of other conditions (e.g., idiopathic postprandial syndrome) in which symptoms suggestive of hypoglycaemia occur, but low glucose levels cannot be demonstrated. The criteria are now invoked far more often by endocrinologists than by surgeons. The radiological investigation of choice now is endoscopic and/or intraoperative ultrasonography.


Differential diagnosis

Whipple's triad is not exclusive for insulinoma, and other conditions will also be considered. The same signs may be caused by hyperinsulinism not caused by insulinoma.


History

The criteria date back to the 1930s, when a few patients with hypoglycaemic symptoms (such as shakiness, syncope, or sweating) due to hypoglycaemia were found to be cured by
surgery Surgery is a medical specialty that uses manual and instrumental techniques to diagnose or treat pathological conditions (e.g., trauma, disease, injury, malignancy), to alter bodily functions (e.g., malabsorption created by bariatric surgery s ...
to remove an insulinoma, but a large proportion of people with symptoms suggestive of hypoglycaemia apparently had no need of surgery. Diagnostic testing was rudimentary; beyond a crude assay for reducing substances as an indirect measure of blood
glucose Glucose is a sugar with the Chemical formula#Molecular formula, molecular formula , which is often abbreviated as Glc. It is overall the most abundant monosaccharide, a subcategory of carbohydrates. It is mainly made by plants and most algae d ...
, no way had yet been found to measure
hormone A hormone (from the Ancient Greek, Greek participle , "setting in motion") is a class of cell signaling, signaling molecules in multicellular organisms that are sent to distant organs or tissues by complex biological processes to regulate physio ...
s and metabolites such as
insulin Insulin (, from Latin ''insula'', 'island') is a peptide hormone produced by beta cells of the pancreatic islets encoded in humans by the insulin (''INS)'' gene. It is the main Anabolism, anabolic hormone of the body. It regulates the metabol ...
, with no imaging procedures for internal organs such as the
pancreas The pancreas (plural pancreases, or pancreata) is an Organ (anatomy), organ of the Digestion, digestive system and endocrine system of vertebrates. In humans, it is located in the abdominal cavity, abdomen behind the stomach and functions as a ...
. Allen Whipple was a well-known surgeon who had pioneered pancreatic surgery. He proposed that no pancreatic surgery to look for insulinoma be performed unless these criteria were met. For this reason, Whipple's triad is also known as Whipple's criteria.


See also

* Hyperinsulinism *
Hypoglycemia Hypoglycemia (American English), also spelled hypoglycaemia or hypoglycæmia (British English), sometimes called low blood sugar, is a fall in blood sugar to levels below normal, typically below 70 mg/dL (3.9 mmol/L). Whipple's tria ...
* Causes of hypoglycemia


References

{{DEFAULTSORT:Whipple's Triad Symptoms and signs: Endocrinology, nutrition, and metabolism Medical triads Eponyms in medicine