# Situation: A 44-year-old man has chronic pancreatitis from long-term alcohol use and stopped drinking 3 months ago. He has diabetes caused by the pancreatitis and uses insulin glargine and insulin lispro. He also takes pancrelipase capsules. His glucose falls faster and lower than expected whenever he misses a meal, and he has needed help to treat some episodes. Which explanation BEST accounts for this pattern?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630503  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 44-year-old man has chronic pancreatitis from long-term alcohol use and stopped drinking 3 months ago. He has diabetes caused by the pancreatitis and uses insulin glargine and insulin lispro. He also takes pancrelipase capsules.

His glucose falls faster and lower than expected whenever he misses a meal, and he has needed help to treat some episodes. Which explanation BEST accounts for this pattern?

## 보기

1. Pancrelipase speeds the absorption of injected insulin
2. Loss of the pancreatic cells that secrete glucagon **✔ 정답**
3. Stronger insulin resistance than in type 2 diabetes
4. Glargine that peaks sharply a few hours after injection

**정답: 2**

## 해설

Chronic pancreatitis destroys islet cells as well as exocrine tissue, so diabetes caused by pancreatitis involves loss of both insulin and glucagon. Without glucagon to raise glucose, hypoglycemia after a missed meal is faster and more severe. He should carry fast-acting glucose, and his family should know how to treat severe lows.

## 심화 해설

Loss of glucagon in pancreatogenic diabetes
Chronic pancreatitis destroys not only the exocrine tissue that makes digestive enzymes but also the islets of Langerhans. These islets contain beta cells that secrete insulin and alpha cells that secrete glucagon. Diabetes caused by pancreatic disease, called pancreatogenic diabetes (type 3c), therefore involves loss of both hormones. Without glucagon to raise glucose, hypoglycemia after a missed meal is faster and more severe. This explains why his lows are deeper than expected and why he has needed help to treat some episodes.

Why glucagon matters
Normally, when glucose falls, alpha cells release glucagon, which stimulates the liver to break down glycogen and make new glucose. Glucagon is one of the body's first and most important defenses against hypoglycemia. In pancreatogenic diabetes, this defense is impaired, and injected insulin acts unopposed. Malabsorption from exocrine insufficiency and poor intake can add to the risk, and if he were to resume alcohol, that would impair liver glucose output further.

| Explanation | Accurate? | Reason |
| --- | --- | --- |
| Pancrelipase speeds insulin absorption | No | Pancrelipase acts on food in the gut only |
| Loss of glucagon-secreting cells | Yes | Removes a key defense against lows |
| Stronger insulin resistance | No | Would raise glucose, not cause severe lows |
| Glargine peaks sharply | No | Glargine has minimal peak |

Why the other explanations are wrong
Pancrelipase digests food in the intestine and has no effect on how injected insulin is absorbed from the subcutaneous tissue. Insulin resistance, a feature of type 2 diabetes, raises glucose and increases insulin needs; it does not cause frequent severe hypoglycemia. Insulin glargine is a basal insulin designed to have a relatively flat profile without a sharp peak, so its timing does not explain lows linked to missed meals. Watch out! Clients with pancreatogenic diabetes can behave like "brittle" diabetes, with swings that standard type 2 reasoning does not explain.

Nursing implications
He should carry fast-acting glucose at all times, eat regular meals and snacks, take pancrelipase so nutrients are absorbed, and avoid alcohol. His family should know how to recognize and treat severe hypoglycemia, including the use of glucagon when he cannot swallow. Key point! Pancreatogenic diabetes combines insulin and glucagon deficiency, so lows are more frequent, faster, and more severe.

## 임상 시나리오

Pancreatogenic Diabetes and HypoglycemiaWhy lows are faster and more severe
Chronic pancreatitis destroys islet cells, so both insulin and glucagon are lost in diabetes caused by pancreatitis.

Without glucagon to raise glucose, injected insulin acts unopposed and lows after a missed meal are faster and deeper.

Teach regular meals and snacks, carrying fast-acting glucose, avoiding alcohol, and family training in treating severe lows.

CautionSevere hypoglycemia in a client who cannot swallow needs glucagon or intravenous glucose; do not give food or fluids by mouth.

## 핵심 개념

- **Pancreatogenic diabetes** — Diabetes caused by disease of the exocrine pancreas, such as chronic pancreatitis, with loss of insulin and glucagon.
- **Alpha cells** — Islet cells of the pancreas that secrete glucagon in response to low blood glucose.
- **Glucagon** — A hormone that raises blood glucose by stimulating glycogen breakdown and glucose production in the liver.
- **Islets of Langerhans** — Clusters of endocrine cells in the pancreas that secrete insulin, glucagon, and other hormones.

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