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Postprandial hyperinsulinemia hypoglycaemia

Position Statement on postprandial hyperinsulinemia hypoglycaemia

The intent is to provide objective information regarding postprandial hyperinsulinemia hypoglycaemia after bariatric surgery
Several therapeutic options include; dietary modifications, medical management, gastrostomy tube placement, gastric pouch restriction, reversal of RYGB, conversion to SG and pancreatectomy

American Society for Metabolic and Bariatric Surgery (ASMBS) has issued a Position statement on postprandial hyperinsulinemia hypoglycaemia after bariatric surgery for the purpose of enhancing quality of care in metabolic and bariatric surgery. The Position Statement includes suggestions for its management, which are derived from available knowledge, peer-reviewed scientific literature, and expert opinion.

The statement, ‘Position Statement on Postprandial Hyperinsulinemic Hypoglycemia after Bariatric Surgery’, published online and in the journal SOARD, was the result of a systematic review of currently available literature regarding postprandial hyperinsulinemia hypoglycaemia after bariatric surgery. According to the authors, “The intent is to provide objective information regarding postprandial hyperinsulinemia hypoglycaemia after bariatric surgery.”

Postprandial hyperinsulinemia hypoglycaemia after bariatric surgery is an uncommon and rarely reported metabolic complication of weight loss surgery, most commonly associated with Roux-en-Y gastric bypass (RYGB). It is distinguished from fasting hypoglycaemia in that it occurs after a meal, with biochemical detection of postprandial hyperinsulinemia and hypoglycaemia.

The statement notes that postprandial hyperinsulinemia hypoglycaemia should be suspected when postprandial neuroglycopenic symptoms occur after bariatric surgery including; confusion, altered levels of consciousness, reduced cognition, weakness, fatigue, warm sensation, slurred speech, and visual disturbances - in the setting of documented low blood glucose levels. Crucially, persistent or unrecognised hypoglycaemia can progress to severe symptoms such as hypoglycaemia unawareness, loss of consciousness, seizures, coma, and even death.

Postprandial hyperinsulinemia hypoglycaemia after bariatric surgery initially thought to be due to endogenous hyperinsulinemia from increased beta-cell mass hyperfunctioning islet cells. However, most experts now agree that the factors responsible for recalcitrant symptoms of hyperinsulinemia hypoglycaemia after bariatric surgery are related to the anatomic changes that occur with surgery resulting in alterations in glucose kinetics, changes in multiple glucose regulatory mechanisms, as well as gastrointestinal and pancreatic hormone levels involved in glucose homeostasis, and not from an inherent change in pancreatic beta-cell mass related to RYGB.

The statement adds that the management of postprandial hyperinsulinemia hypoglycaemia is particularly challenging due to its variable clinical presentation and a pathophysiology not yet fully elucidated. Several therapeutic options include; dietary modifications, medical management, gastrostomy tube placement, gastric pouch restriction, reversal of RYGB, conversion to SG and pancreatectomy.

In summary, the the Position Statement has the following recommendations for patients with postprandial hyperinsulinemia hypoglycaemia after bariatric surgery:

  • Postprandial hyperinsulinemia hypoglycaemia after bariatric surgery is rare and most commonly associated with RYGB. Nonetheless, patients should be screened for, educated, and counselled to recognize the signs and symptoms of hypoglycaemia.
  • Extreme, progressive, unrecognized neuroglycopenic symptoms of postprandial hyperinsulinemia hypoglycaemia can result in cognitive and neurologic impairment with risk of seizures and loss of consciousness posing risk to both patient and others.
  • Insulinoma must be ruled out in patients with confirmed fasting hypoglycaemia.
  • Diagnosis of postprandial hyperinsulinemia hypoglycaemia requires a dietary journal, along with confirmatory laboratory and provocative testing, in the setting of symptoms presenting more than 1 year after surgery. Treatment with dietary modification in mild cases is often implemented successfully without a definitive diagnosis.
  • Postprandial hyperinsulinemia hypoglycaemia can be effectively treated in the majority of cases with dietary modification alone. A dietitian should be an integral part of the treatment team, and an endocrinologist consulted in cases not responding to initial treatment.
  • Pharmacotherapy produces variable results, but should be attempted before surgical intervention. A gastrostomy tube with feeding into the remnant stomach provides nutritional support and in some cases symptomatic relief and should be considered in patients not responding to nonoperative treatment. Partial pancreatectomy is not recommended.

The ASMBS notes that the Position Statement may be revised in the future should additional evidence become available.

The position Statement was prepared by Drs Dan Eisenberg, Dan E Azagury, Saber Ghiassi, Brandon T Grover and Julie J Kim.

To access the Position Statement, please click here

To view in a pdf (published in SOARD), please click here

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American Society for Metabolic and Bariatric Surgery

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