SUN-LB058 Metastatic Insulinoma after Bariatric Surgery: A Diagnostic Challenge

Abstract

Background : Post bariatric hypoglycemia (PBH) is an increasingly recognized complication of bariatric surgery. Onset typically occurs more than 1-year post-op with episodes typically occurring postprandially. In contrast, insulinoma causes fasting and postprandial hypoglycemia and has been described after bariatric surgery, with 9 reported cases. Case : A 69-year-old woman presented to the emergency department after syncope in the setting of hypoglycemia to 39 mg/dL. Medical history was notable for Roux-en-Y gastric bypass 9 years ago. She had been experiencing fatigue in the 8 months prior with episodes of diaphoresis, hunger and mental fogginess that occurred randomly throughout the day and resolved with hard candy. An inpatient supervised fast resulted in Whipple triad with blood glucose 32 mg/dL and insulin 28 uU/mL (N 2.6-24.4) within 3 hrs of starting the test, thus making it difficult to exclude PBH. Therefore, a repeat fast was performed after minimal carbohydrate intake. This test yielded similar results with hypoglycemia occurring within 2.5 hrs. Based on this, medical treatment with octreotide and diazoxide was initiated. CT abdomen showed atrophic pancreas with no mass and an enhancing liver mass suggestive of a hemangioma. However, MRI abdomen revealed a 2.9 cm pancreatic tail mass and 3 hypervascular liver lesions concerning for metastasis. Subsequently, biochemical results from the supervised fast confirmed hyperinsulinemic hypoglycemia likely due to metastatic insulinoma based on imaging studies: C-peptide 4.67 ng/mL (N 0.8-3.85), proinsulin >800 pmol/L (N <=18.8), ß hydroxy butyrate 0.04 mmol/L (N <= 0.28). Pancreatic mass FNA via endoscopic ultrasound was suspicious for neuroendocrine tumor (NET). Liver mass biopsy showed metastatic NET. Hypoglycemia worsened despite continuous IV dextrose infusion and medical therapy necessitating distal pancreatectomy, splenectomy and partial hepatectomy for tumor debulking. Pathology revealed a 1.4 cm grade 2 well- differentiated NET in the pancreatic tail (mitotic rate 1 per 10 hpfs, Ki67 5%) and 2 foci of metastasis in the liver (8 and 0.9 cm). Unfortunately, the patient developed unexplained refractory shock with multiorgan failure post-operatively and passed away after 7 days. Conclusion :To our knowledge, this is the first case reported of malignant insulinoma after bariatric surgery. Malignant metastatic insulinoma is very rare. It causes severe hypoglycemia that can occur in the very early PP period similar to PBH, which could delay diagnosis. Inconclusive initial imaging should not preclude comprehensive workup in severe persistent hypoglycemia. Reference : Mulla, CM et al. Insulinoma After Bariatric Surgery: Diagnostic Dilemma and Therapeutic Approaches. Obes Surg . 2016. 26:874-881 Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the a...

Metastatic insulinoma presenting after bariatric surgery in a patient diagnosed with MEN1

“…3 This is the second reported case of metastatic insulinoma presenting after bariatric surgery, the first being in abstract form. 2 The differential diagnosis for hypoglycemia is broad but in the seemingly well patient such as ours, it should include insulinoma, post-bariatric hypoglycemia, NIPHS, insulin autoimmune hypoglycemia, medications, and factitious hypoglycemia. 4 Given the patient's history of sleeve gastrectomy, post-bariatric hypoglycemia was a consideration.…”

“… 3 This is the second reported case of metastatic insulinoma presenting after bariatric surgery, the first being in abstract form. 2 …”

“… 1 To the best of our knowledge, this is the second reported case of metastatic insulinoma presenting after bariatric surgery. 2 …”

Insulinoma After Bariatric Surgery: Tricks for Diagnosis and Therapeutic Approach

“…Insulin resistance caused by the obesity as well as lack of awareness of symptoms of hypoglycemia by the patients, may contribute to the delay in the identification of the insulinoma. Patients often fail to recognize autonomic warning symptoms and the hypoglycemia is only detected through the presence of neuroglycopenic symptoms delaying the diagnosis of the insulinoma for up to 5 years [21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37].…”