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Conservative approach for post-bypass hypoglycaemia

Persistent hypoglycaemia despite continuous D10 infusion supports the hypothesis of increased stimulation of insulin release in NIPHS

Patients presenting with hypoglycaemia following a gastric bypass can be treat effectively with a conservative approach which avoids expensive and unnecessary invasive studies, according to a case study (‘‘Conservative management in persistent hypoglycaemia: a cost effective option’, abstract No. 409) presented at the American Association of Clinical Endocrinologists’ annual meeting in Las Vegas.

They researchers from SUNY Upstate Medical University, NY, found that using this approach, with dietary modification, was successful in managing the condition, as well as preventing the patient from having to undergo invasive studies that can reduce their morbidity allowing them to maintain a good quality of life.

They said that incidents of post-gastric bypass surgery hypoglycaemia may increase with the rise in such procedure numbers and there is “uncertainty” as to the pathophysiologic mechanisms. With an estimated <1% post-gastric patients developing severe hypoglycaemia an optimal management strategy is required.

The case study concerned a 50 year old Caucasian female who was found unconscious at home. She had a gastric bypass surgery one year ago, with no diabetes mellitus or previous syncopal episodes.  Her physical examination, preliminary labs and CT head revealed nothing except low blood glucose on BMP.

A 72 hour fasting test was discontinued in two hours due to symptomatic hypoglycaemia with blood glucose 47mg/dL, and simultaneous blood work showed normal insulin (8.4 uU/mL), proinsulin (6.0 pmol/L) and C peptide levels (3.0 ng/mL) with low beta-hydroxybutyrate (0.03 mmol/L), consistent with Insulinoma vs non-insulinoma pancreatogenous hypoglycaemia syndrome (NIPHS). The CT abdomen and an octreotide scan were normal.

The patient elected not to undergo invasive testing with selective arterial calcium stimulation test (SACST) or endoscopic ultrasound, but agreed to initiate conservative management with frequent small meals of high protein content without large carbohydrate loads. Since then, her BG has been well maintained with no new syncopal episodes.

“This unique case of persistent hypoglycemia despite continuous D10 infusion supports the hypothesis of increased stimulation of insulin release in NIPHS,” the researchers said. “In contrary to multiple previous reports, invasive testing, including SACST and diagnostic and therapeutic laparotomies was not required. We expect that the incidence of this [hypoglycaemia] will increase, with increasing rates of gastric bypass procedures. Raising awareness of an effective conservative approach with dietary modification is helpful for successful and safe management.”

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