Whipple Triad: Definition, History and Current Use

It is a collection of three criteria that suggest that a patient’s symptoms result from hypoglycemia, which may indicate insulinoma.

A diagnosis of hypoglycemia is not based solely on symptoms. On the contrary, endocrinologists look for the presence of Whipple’s triad. These three factors help doctors diagnose hypoglycemia or low blood sugar levels (blood glucose).

The triad of Whipple is the clinical presentation of pancreatic insulinomas, it is established in several versions, but the necessary conditions are:

  • Symptoms known or that may be caused by hypoglycemia, especially after fasting or intense exercise, fasting hypoglycemia (<50 mg/dl) low blood glucose level.
  • Low plasma glucose (in plasma), measured by a precise method at the time of symptoms, is also called hypoglycemia symptoms at a low glucose level.
  • Immediate relief of symptoms after administration of IV glucose, when glucose rises to normal.

The symptoms of hypoglycemia are:

  • Neuroglucopenic symptoms include behavioral changes, fatigue, seizures, and altered consciousness.
  • Adrenergic symptoms such as palpitations, tremors, and anxiety.
  • Cholinergic symptoms such as sweating, hunger, and altered sensations.

The cutoff value for hypoglycemia is 70 mg / dL, equal to 3.9 mmol / L.

The relief of symptoms can be done as follows:

  • Initially, 20 mg of carbohydrates containing fluids or foods can be administered if the patient can tolerate them orally.
  • Intravenous glucose 25g of bolus at 2mg / kg / min followed by 10g / h. 250 ml of 10% dextrose is better than 50 ml of 50% dextrose as there is less thrombophlebitis.
  • Glucagon 1mg subcutaneously or intramuscularly works as fast as dextrose and is a suitable method for no intravenous access. The patient is unconscious, but it will not work in a drunk patient.

Whipple’s triad clinically characterizes insulinomas: episodic hypoglycemia, central nervous system (CNS) dysfunction temporarily related to hypoglycemia (confusion, anxiety, stupor, paralysis, convulsions, coma), and dramatic reversal of significant jumpy system abnormalities by glucose administration.


When the Whipple triad is mentioned, one thinks classically of insulinomas, but these characteristics are not insulinoma specific.

According to the textbook, Henry’s Clinical Diagnosis and Management by Laboratory Methods, a blood glucose level equal to or lower than 50 mg / dL (average blood glucose is 80-120) without diabetes justifies an adequate medical evaluation.

A blood test diagnoses fasting or reactive hypoglycemia to measure the blood glucose. The test can be done after fasting during the night, physical activity, or between meals.

Of course, if your endocrinologist suspects a hormonal deficiency, a pancreatic tumor, or another cause of hypoglycemia, more testing and evaluation are required.


Like a good piece of trivia, one might suspect that Whipple’s disease, Whipple’s triad, and Whipple’s procedure, since they are all grouped around the same region, would all have been named Whipple himself.

There are two Whipples. One for the disease and another for the triad and the procedure. He was appointed by Allen Oldfather Whipple (1881-1963), an American surgeon.

The criteria date back to the 1930s when it was discovered that some patients with symptoms of hypoglycemia (such as tremors, syncope, or sweating) due to hypoglycemia could be cured by surgery to remove an insulinoma.

However, it also became evident that many people with symptoms suggestive of hypoglycemia did not need surgery.

Diagnostic tests were rudimentary: beyond a crude trial to reduce substances as an indirect measure of blood glucose; there was no way to measure hormones and metabolites such as insulin or imaging procedures for internal organs such as the pancreas.

Allen O. Whipple was a well-known surgeon who pioneered pancreatic surgery. In an article entitled “Surgical therapy of hyperinsulinism,” in J Internat Chir 3: 237-276 (1938), he proposed that pancreatic surgery should not be performed to look for an insulinoma unless these criteria are met.

Current use of the Whipple triad

The use and importance of the criteria have evolved over the last century as our understanding of the various forms of hypoglycemia increases and our diagnostic tests and imaging procedures have improved.

The Whipple criteria are no longer used to justify the surgical exploration of an insulinoma but to separate “true hypoglycemia” (in which low glucose can be demonstrated) from a variety of other conditions (e.g., postprandial syndrome). idiopathic) symptoms suggest hypoglycemia, but low glucose levels can not be shown.

The criteria are now invoked much more frequently by endocrinologists than by surgeons.