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patient, the effusion is initially drained percutaneously Early attempts at ballooning the pericardium from a subxiphoid approach have been mostly abandoned in favor of surgical approaches A pericardial window, either by a subxiphoid approach or via video-assisted thoracic surgery, allows for partial pericardiectomy Instillation of chemotherapeutic agents or tetracycline may occasionally be used to reduce the recurrence rate Aspirin or other nonsteroidal anti-inflammatory agents in dosages given for viral pericarditis above for 2 4 weeks are usually effective for the treatment of postmyocardial infarction or postcardiotomy pericarditis (Dressler s syndrome) In more severe cases, corticosteroids should be given in rapidly tapering doses Relapses do occur and may require slow withdrawal of anti-inflammatory therapy over several months Colchicine may be required for months to help prevent recurrences Symptomatic therapy is the initial approach to radiation pericarditis, but recurrent effusions and constriction often require surgery

Imazio M et al Management, risk factors, and outcomes in recurrent pericarditis Am J Cardiol 2005 Sep 1;96(5):736 9 [PMID: 16125506] Lee PJ et al Cardiovascular effects of radiation therapy: practical approach to radiation therapy-induced heart disease Cardiol Rev 2005 Mar Apr;13(2):80 6 [PMID: 15705258] Ross AM et al Acute pericarditis Evaluation and treatment of infectious and other causes Postgrad Med 2004 Mar;115(3): 67 70, 73 5 [PMID: 15038256] Talreja DR et al Constrictive pericarditis in 26 patients with histologically normal pericardial thickness Circulation 2003 Oct 14;108(15):1852 7 [PMID: 14517161] Troughton RW et al Pericarditis Lancet 2004 Feb 28;363 (9410):717 27 [PMID: 15001332]

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After the diagnosis of insulinoma has been unequivocally made by clinical and laboratory findings, studies to localize the tumor should be initiated The focus of attention should be directed to the pancreas since that is where virtually all insulinomas originate A spiral CT angiography of the pancreas should be performed to rule out a large tumor of the pancreas or hepatic metastases from a malignant islet cell tumor Endoscopic ultrasonographic examination of the pancreas can also be helpful in identifying the pancreatic lesions Because of the small size of these tumors (averaging 15 cm in diameter in one large series), imaging studies do not necessarily identify all the tumors Patients who do not have an obvious tumor on imaging (but have a definite biochemical diagnosis) should undergo selective calcium-stimulated angiography In this test, angiography is combined with injections of calcium gluconate into the gastroduodenal, splenic, and superior mesenteric arteries and insulin levels are measured in the hepatic vein effluent Calcium stimulates insulin release from insulinomas but not normal islets, and so a step-up of insulin levels regionalizes the hyperinsulinism to the head of the pancreas for the gastroduodenal artery, to the uncinate process for the superior mesenteric artery, and to the body and tail of the pancreas for the splenic artery This technique may also provide data that are particularly helpful when multiple insulinomas are suspected (MEN 1) and it has become a

In patients with inoperable functioning islet cell carcinoma and in approximately 5 10% of MEN 1 cases when subtotal removal of the pancreas has failed to produce cure, reliance on frequent feedings is necessary Since most tumors are not responsive to glucose, carbohydrate feedings every 2 3 hours are usually effective in preventing hypoglycemia, although obesity may become a problem Diazoxide, 300 600 mg (or 3 mg to 8 mg/kg; 50 mg/mL oral suspension) daily orally in two or three divided doses, is the treatment of choice Hydrochlorothiazide, 25 50 mg daily, should also be prescribed to counteract the sodium retention and edema secondary to diazoxide therapy as well as to potentiate its hyperglycemic effect If patients are unable to tolerate diazoxide because of gastrointestinal upset, hirsutism, or edema, the calcium channel blocker verapamil may be beneficial in view of its inhibitory effect on insulin release from insulinoma cells Octreotide, a potent long-acting synthetic

octapeptide analog of somatostatin, has been used to inhibit release of hormones from a number of endocrine tumors A dose of 50 mcg of octreotide injected subcutaneously twice daily has been tried in cases where surgery failed to remove the source of hyperinsulinism However, its effectiveness is limited since its affinity for somatostatin receptors of the pancreatic B cell is very much less than for those of the anterior pituitary somatotrophs for which it was originally designed as treatment for acromegaly When hypoglycemia persists after attempted surgical removal of the insulinoma and if diazoxide or verapamil is poorly tolerated or ineffective, multiple small feedings may be the only recourse until more selective somatostatin receptor agonists are available Streptozocin can decrease insulin secretion in islet cell carcinomas, and effective doses have been delivered via selective arterial catheter so that the undue renal toxicity that characterized early experience is less of a problem

When insulinoma is diagnosed early and cured surgically, complete recovery is likely, although brain damage following prolonged severe hypoglycemia is not reversible A significant increase in survival rate has been shown in streptozocintreated patients with islet cell carcinoma, with reduction in tumor mass as well as decreased hyperinsulinism

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