Hypoglycaemia following upper gastrointestinal surgery: case report and review of the literature

Abstract

BackgroundHyperinsulinemic hypoglycemia is relatively recently recognized in persons undergoing bariatric surgery although knowledge and experience with this condition may not be commensurate with the number of such procedures being performed globally. This paper presents a novel case as an example of how such patients may present and how they may be investigated.Case PresentationA 69-year-old man was assessed 3 months post-fundoplication surgery for postprandial hypoglycaemia with neuroglycopenia that became progressively severe. A 72-h fast failed to show hypoglycaemia. During a clinic visit, the patient became confused and had a low plasma glucose, high plasma insulin, and high plasma C-peptide; symptoms were relieved with glucose. No tumours were visualized on CT, MRI, or endoscopic ultrasound. A total body Indium111-octreotide scan was negative. Selective arterial calcium stimulation showed a high insulin gradient in the splenic and superior mesenteric arteries, suggesting diffuse pancreatic beta cell hyperplasia. The patient declined pancreatic resection and recurrent symptomatic hypoglycaemia was successfully prevented with low dose octreotide.ConclusionsAlthough increasingly recognized following bariatric surgery, this is the first reported development of NIPHS (non-insulinoma pancreatogenous hypoglycemia syndrome) following fundoplication surgery, as well as the first documented use of octreotide in post-operative NIPHS. Medical management may be an alternative to surgery for patients with this rare condition.

Interdisciplinary European guidelines on metabolic and bariatric surgery

“…Criteria for assessment of effect of bariatric surgery on optimization of metabolic status and some other co-morbid conditions [58] : -HbA1c ≤ 6%, no hypoglycaemia, total cholesterol < 4 mmol/l, LDL-cholesterol < 2 mmol/l, triglycerides < 2.2 mmol/l, blood pressure < 135/85 mmHg, >15% weight loss, or lowering of HbA1c by >20%, LDL< 2.3 mmol/l, blood pressure < 135/85 mm Hg with reduced medication from pre-operative status. In cases of postprandial hypoglycaemic symptoms, evidence for lowered blood glucose concurrent with symptoms should be looked for; patients should first be advised on dietary changes (low carbohydrate diets, regular meal times); second-line drug treatment may be considered, such as acarbose, calcium-channel antagonists, diazoxide, octreotide (EL C [188][189][190][191][192] .) Special care must be taken for: -The possible nutritional deficiencies such as vitamin, protein and other micronutrients.…”

Hypoglycemia episodes after biliopancreatic diversion for morbid obesity: clinical case presentation

“…Развитие гипогликемических состояний после билиопанкреатического шунтирования по поводу морбидного ожирения: клинический случай С л у ч а й и з п р а к т и к и Вместе с тем, в последнее десятилетие появились сообщения о возможности развития тяжелых гипо-гликемических состояний, вплоть до незидиобластоза, у пациентов, перенесших гастрошунтирование [7].…”

Management of the post-bariatric surgery patient – what an internist needs to know

“…It is frequently identified with dumping syndrome, although in distinction to hyperinsulinemic hypoglycemia, DS rarely presents with symptoms of neuroglycopenia [41]. Postprandial hypoglycemia tends to develop usually 2 to 9 years after gastric bypass [41].…”

“…It is frequently identified with dumping syndrome, although in distinction to hyperinsulinemic hypoglycemia, DS rarely presents with symptoms of neuroglycopenia [41]. Postprandial hypoglycemia tends to develop usually 2 to 9 years after gastric bypass [41]. Patients presenting neuroglycopenic symptoms, who do not respond to nutritional modification, should be evaluated to differentiate dumping syndrome, insulinoma and noninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS) [42,43].…”