A man in his mid-30s presented to the emergency department following a motor vehicle accident with critically low blood glucose of 1.1 mmol/L (3.9-5.6 mmol/L) noted by emergency medical service and altered mental status. The patient reported progressive symptoms including tremor, sweating and difficulty concentrating, requiring continuous eating throughout the day, weight gain and hypoglycaemia unawareness.A 72-hour supervised fast confirmed endogenous hyperinsulinaemia, after 5 hours, inappropriately elevated insulin of 26 pmol/L (diagnostic cut-off ≥18 pmol/L) and C-peptide >0.33 nmol/L (expected <0.2 nmol/L) with glucose 2.2 mmol/L (3.9-5.6 mmol/L). While CT and DOTATATE-positron emission tomography were negative, endoscopic ultrasound (EUS) and biopsy identified a 13 mm pancreatic head well-differentiated neuroendocrine tumour.EUS-guided radiofrequency ablation (EUS-guided RFA) achieved immediate symptom resolution with normal postprocedure biochemical profile. In this case, EUS successfully identified the lesion when conventional imaging was negative and EUS-guided RFA resulted in successful treatment in this patient.
Zekarias et al. (2026) studied this question.