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Gastric Bypass pp 307-313 | Cite as

Hypoglycemia After Gastric Bypass

  • Glauco da Costa Alvarez
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Abstract

Hypoglycemia after Roux-en-Y gastric bypass is a rare and challenging condition. It occurs several months to years after surgery and has been more commonly seen in females. Severe hypoglycemia presents with symptoms of the Whipple’s triad that include signs as perspiration, palpitations, hunger, fatigue, confusion, aggression, tremor, syncope, a low plasma glucose concentration, and resolution of those symptoms after carbohydrate intake. Specific symptoms of hypoglycemia are categorized as autonomic or neuroglycopenic. Autonomic symptoms include anxiety, sweating, tremors, and palpitation. Neuroglycopenic symptoms comprehend confusion, weakness, light-headedness, dizziness, blurred vision, disorientation, and eventually, loss of consciousness, coma, and death.

When the patient is symptomatic, a fasting plasma glucose <50 mg/dl with serum insulin level is the first step for the decision-making process. Hyperinsulinemia is a condition in which the insulin level is above 6 mμU/ml and C-peptide elevated >5 ng/ml. A proinsulin level <5 pmol/L is a highly sensitive clue on eliminating insulinoma as a cause of endogenous hyperinsulinemia. The mixed meal tolerance test (MMTT) is the preferred provocative test. Most patients with post-RYGB hypoglycemia benefit from dietary restrictions or more complex nutritional and medical management strategies, including acarbose, nifedipine, diazoxide, GLP-1 receptor antagonist, and octreotide.

If the response is not adequate, surgery may be considered to alleviate the symptoms. Gastrostomy tube placement and/or addition of restriction, before reversal of the RYGB have been used as alternatives. Partial pancreatectomies are indicated only in exceptional cases.

Keywords

Postprandial hyperinsulinemic hypoglycemia Hypoglycemia-like Hyperinsulinemia Nesidioblastosis RYGB Dumping syndrome Distal pancreatectomy Morbid obesity Glucagon-like peptide 1 Bariatric surgery 

References

  1. 1.
    Shantavasinkul PC, Torquati A, Corsino L. Post-gastric bypass hypoglycaemia: a review. Clin Endocrinol (Oxf). 2016;85:3–9.CrossRefGoogle Scholar
  2. 2.
    Rariy CM, Rometo D, Korytkowski M. Post-gastric bypass hypoglycemia. Curr Diab Rep. 2016;16:19.PubMedCrossRefGoogle Scholar
  3. 3.
    Marsk R, Jonas E, Rasmussen F, Naslund E. Nationwide cohort study of post-gastric bypass hypoglycaemia including 5,040 patients undergoing surgery for obesity in 1986–2006 in Sweden. Diabetologia. 2010;53:2307–11.CrossRefGoogle Scholar
  4. 4.
    Kellogg TA, Bantle JP, Leslie DB, Redmond JB, Slusarek B, Swan T, et al. Postgastric bypass hyperinsulinemic hypoglycemia syndrome: characterization and response to a modified diet. Surg Obes Relat Dis. 2008;4:492–9.CrossRefGoogle Scholar
  5. 5.
    Bueter M, Ashrafian H, le Roux CW. Mechanisms of weight loss after gastric by-pass and gastric banding. Obes Facts. 2009;2:325–31.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    le Roux CW, Welbourn R, Werling M, et al. Gut hormones as mediators os appetite and weight loss after Roux-en-Y gastric by-pass. Ann Surg. 2007;246:780–5.CrossRefGoogle Scholar
  7. 7.
    Schultes B, Ernst B, Wilms B, Thurnheer M, Hallschmid M. Hedonic hunger is increased in severely obese patients and is reduced after gastric by-pass surgery. Am J Clin Nutr. 2012;92:277–83.CrossRefGoogle Scholar
  8. 8.
    Miras AD, le Roux CW. Bariatric surgery and taste: novel mechanisms of weight loss. Curr Opin Gastroenterol. 2010;26:140–5.PubMedCrossRefGoogle Scholar
  9. 9.
    Tack J, Caenepeel P, De Wulf D, Bisschops R. Pathophysiology, diagnosis and management of postoperative dumping syndrome. Nat Rev Gastroenterol Hepatol. 2009;6:583–90.CrossRefGoogle Scholar
  10. 10.
    Laurenius A, Werling M, le Roux CW, Fandriks L, Olbers T. More symptoms but similar blood glucose curve after oral carbohydrate provocation in patients with a history of hypoglycemia-like symptoms compared to asymptomatic patients after Roux-en-Y gastric by-pass. Surg Obes Relat Dis. 2014;10:1047–55.PubMedCrossRefGoogle Scholar
  11. 11.
    Crapo PA, Scarlett JA, Kolterman OG, Sabders LR, Hofeldt FD, Olefsky JM. The effects of oral fructose, sucrose, and glucose in subjects with reactive hypoglycemia. Diabetes Care. 1982;5:512–7.PubMedCrossRefGoogle Scholar
  12. 12.
    Zagury L, Moreira RO, Guedes EP, Coutinho WF, Appolinario JC. Insulinoma misdiagnosed as dumping syndrome after bariatric surgery. Obes Surg. 2004;14:120–3.PubMedCrossRefGoogle Scholar
  13. 13.
    Harness JK, Geelhoed GW, Thompson NW, et al. Nesidioblastosis in adults. Arch Surg. 1981;116:575–80.PubMedCrossRefGoogle Scholar
  14. 14.
    Service GJ, Thompson GB, Service JF, Andrews JC, Collazo-Clavell ML, Lloyd RV. Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric bypass surgery. N Engl J Med. 2005;353:249–54.CrossRefGoogle Scholar
  15. 15.
    Z’graggen K, Guwweidhi A, Steffen R, et al. Severe recurrent hypoglycemia after gastric by-pass surgery. Obes Surg. 2008;18:981–8.CrossRefGoogle Scholar
  16. 16.
    Holst JJ. Glucagonlike peptide 1: a newly discovered gastrointestinal hormone. Gastroenterology. 1994;107:1848–55.PubMedCrossRefGoogle Scholar
  17. 17.
    Goldfine AB, Mun EC, Devine E, et al. Patients with neuroglycopenia after gastric by-pass surgery have exaggerated incretin and insulin secretory responses to a mixed meal. J Clin Endocrinol Metab. 2007;92:4678–85.PubMedCrossRefGoogle Scholar
  18. 18.
    Rabiee A, Magruder JT, Salas-Carrillo R, et al. Hyperinsulinemic hypoglycemia after Roux-en-Y gastric by-pass: unraveling the role of gut hormonal and pancreatic endocrine dysfunction. J Surg Res. 2011;167:199–205.PubMedCrossRefGoogle Scholar
  19. 19.
    Patti M, Goldfine AB. Hypoglycemia after gastric by-pass: the dark side of GLP-1. Gastroenterology. 2014;146:605–08. J Surg Res. 2011;167:199–205.PubMedPubMedCentralCrossRefGoogle Scholar
  20. 20.
    Meier JJ, Butler AE, Galasso R, Butler PC. Hyperinsulinemic hypoglycemia after gastric bypass surgery is not accompanied by islet hyperplasia or increased beta cell turnover. Diabetes Care. 2006;29:1554–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Butler PC, Meier JJ, Butler AE, Bhusshan A. The replication of beta cells in normal physiology, in disease and for therapy. Nat Clin Pract Endocrinol Metab. 2007;3:758–68.PubMedCrossRefGoogle Scholar
  22. 22.
    Kamvissi V, Salerno A, Bornstein SR, Mingrone G, Rubino F. Incretins or -incretins? A new model for the ëntero-pancreatic axis. Horm Metab Res. 2015;47:84–7.PubMedGoogle Scholar
  23. 23.
    Tack J, Arts J, Caenepeel P, De Wulf D, Bisschops R. Pathophysiology, diagnosis and management of postoperative dumping syndrome. Nat Rev Gastroenterol Hepatol. 2009;6:583–56.CrossRefGoogle Scholar
  24. 24.
    Cryer PE, Axelrod L, Grossman AB, et al. Evaluation and management of adult hypoglycemic disorders: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009;94:709–28.PubMedCrossRefGoogle Scholar
  25. 25.
    Vezzosi D, Bennet A, Fauvel J, Caron P. Insulin, C-peptide and proinsulin for the biochemical diagnosis of hypoglycemia related to endogenous hyperinsulinism. Eur J Endocrinol. 2007;157:75–83.PubMedCrossRefGoogle Scholar
  26. 26.
    Malik S, Mitchell JE, Steffen K, Engel S, Wiisanen R, Garcia L, et al. Recognition and management of hyperinsulinemic hypoglycemia after bariatric surgery. Obes Res Clin Pract. 2016;10:1–14.PubMedCrossRefGoogle Scholar
  27. 27.
    Service FJ, Natt N, Thompson GB, et al. Noninsulinoma pancreatogenous hypoglycemia in adults independent of mutations in Kir6.2 and SURI genes. J Clin Endocrinol Metab. 1999;84:1582–9.PubMedGoogle Scholar
  28. 28.
    Bantle JP, Ilkramuddin S, Kellogg TA, Buchwald H. Hyperinsulinemic hypoglycemia developing later after gastric by-pass. Obes Surg. 2007;17:592–4.PubMedCrossRefGoogle Scholar
  29. 29.
    Botros N, Rijnaarts I, Brandts H, Bleumink G, Janssen I, de Boer H. Effect of carbohydrate restriction in patients with hyperinsulinemic hypoglycemia after Roux-en Y gastric by-pass. Obes Surg. 2014;10:36–43.CrossRefGoogle Scholar
  30. 30.
    Ritz P, Vaurs C, Bertrand M, Andruze Y, Guillaume E, Hanaire H. Usefulness of acarbose and dietery modifications to limit glycemic variability following Roux-en-Y gastric by-pass as assessed by continuous glucose monitoring. Diabetes Technol Ther. 2012;14:736–40.CrossRefGoogle Scholar
  31. 31.
    Frankhouser SY, Ahmad AN, Peilli GA, Quintana BJ, Vengrove MA. Post-gastric-bypass hypoglycemia successfully treated with alpha-glucosidase inhibitor therapy. Endocr Pract. 2013;19:511–4.PubMedCrossRefGoogle Scholar
  32. 32.
    Guseva N, Phillips D, Mordes JP. Successful treatment of persistent hyperinsulinemic hypoglycemia with nifedipine in an adult patient. Endocr Pract. 2010;16:107–11.PubMedPubMedCentralCrossRefGoogle Scholar
  33. 33.
    Spanakis E, Gragnoli C. Successful medical management of status post-Roux-en-Y-gastric by-pass hyperinsulinemic hypoglycemia. Obes Surg. 2009;19:1333–4.PubMedPubMedCentralCrossRefGoogle Scholar
  34. 34.
    Salehi M, Progeon RL, D’Alessio DA. Gastric by-pass surgery enhances glucagon-like peptide 1-stimulated postprandial insulin secretion in humans. Diabetes. 2011;60:2308–14.PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Salehi M, Gastaldelli A, D’Alessio DA. Altered islet function and insulin clearance cause hyperinsulinemia in gastric by-pass patients with symptoms of postprandial hypoglycemia. J Clin Endocrinol Metab. 2014;99:2008–17.PubMedPubMedCentralCrossRefGoogle Scholar
  36. 36.
    Salehi M, Gastaldelli A, D’Alessio DA. Blockade of glucagon-like peptide1 receptor corrects postprandial hypoglycemia after gastric by-pass. Gastroenterology. 2014;146:669–80.e2.CrossRefGoogle Scholar
  37. 37.
    Didden P, Penning C, Masclee AA. Octreotide therapy in dumping syndrome: analysis of long term results. Aliment Pharmacol Ther. 2006;24:1367–75.PubMedCrossRefGoogle Scholar
  38. 38.
    Cui Y, Elahi D, Anderson DK. Advances in the etiology and management of hyperinsulinemic hypoglycemia after Roux-en-Y gastric by-pass. J Gastrointest Surg. 2011;15:1879–88.PubMedCrossRefGoogle Scholar
  39. 39.
    Campos GM, Ziemelis M, Paparodis R, Ahmed M, Davis DB. Laparoscopic reversal of Roux-en-Y gastric by-pass: technique and utility for treatment of endocrine complications. Surg Obes Relat Dis. 2014;10:36–43.PubMedCrossRefGoogle Scholar
  40. 40.
    Vilallonga R, van de Vrande S, Himpens J. Laparoscopic reversal of Roux-en-Y gastric by-pass into normal anatomy with or without sleeve gastrectomy. Surg Endosc. 2013;27:4640–8.PubMedCrossRefGoogle Scholar
  41. 41.
    de Heide LJ, Glaudemans AW, Oomen PH, Apers JA, Totté ER, van Beek AP. Functional imaging in hyperinsulinemic hypoglycemia after gastric bypass surgery for morbid obesity. J Clin Endroninol Metab. 2012;97:E963–7.CrossRefGoogle Scholar
  42. 42.
    Z’graggen K, Guweidhi A, Steffen R, et al. Severe recurrent hypoglycemia after gastric by-pass surgery. Obes Surg. 2008;18:981–8.CrossRefGoogle Scholar
  43. 43.
    Mala T. Postprandialhyperinsulinemic hypoglycemia after gastric by-pass surgical treatment. Surg Obes Relat Dis. 2014;10:1220–5.PubMedCrossRefGoogle Scholar
  44. 44.
    Clancy TE, Moore FD Jr, Zimer MJ. Post-gastric by-pass hyperinsulinism with nesidioblastosis: subtotal or total pancreatectomy may be needed to prevent recurrent hypoglicemia. J Gastrointest Surg. 2006;10:1116–9.CrossRefGoogle Scholar
  45. 45.
    Dapri G, Cadiere GB, Himpens J. Laparoscopic reconversion of Roux-en-Y gastric by-pass to original anatomy: technique and preliminary outcomes. Obes Surg. 2011;21:1289–95.PubMedCrossRefGoogle Scholar
  46. 46.
    Lee CJ, Brown T, Magnuson TH, Egan JM, Carlson O, Elahi D. Hormonal response to a mixed-meal challenge after reversal of gastric by-pass for hypoglycemia. J Clin Endocrinol Metab. 2013;98:E1208–12.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Patti ME, McMahon G, Mun EC, et al. Severe hypoglycemia post-gastric by-pass requiring partial pancreatectomy: evidence for inappropriate insulin secretion and pancreatic islet hyperplasia. Diabetologia. 2005;48:2236–40.CrossRefGoogle Scholar
  48. 48.
    Ceppa EP, Ceppa DP, Omotosho PA, Dickerson JA 2nd, Park CW. Algorithm to diagnose etiology of hypoglycaemia after Roux-en-Y gastric by-pass for morbid obesity: case series and review of the literature. Surg Obes Relat Dis. 2012;8:641–7.CrossRefGoogle Scholar
  49. 49.
    Qintar M, Sibai F, Taha M. Hypoglycemia due to an adult-onset nesidioblastosis, a diagnostic and management dilemma. Avicenna J Med. 2012;2:45–7.PubMedPubMedCentralCrossRefGoogle Scholar
  50. 50.
    Rabiee A, Magruder JT, Salas-Carrillo R, et al. Hyperinsulinemic hypoglycemia after Roux-en-Y gastric bypass: unraveling the role of the gut hormonal and pancreatic endocrine function. J Surg Res. 2011;167:199–205.PubMedCrossRefGoogle Scholar
  51. 51.
    Alvarez GC, Faria EN, Beck M, Girardon DT, Machado AC. Laparoscopic spleen-reserving distal pancreatectomy as treatment for nesidioblastosis after gastric by-pass surgery. Obes Surg. 2007;17:550–2.PubMedCrossRefGoogle Scholar
  52. 52.
    Barbour JR, Thomas BN, Morgan KA, Byrne TK, Adams DB. The practice of pancreatic resection after Roux-en-Y gastric by-pass. Am Surg. 2008;74:729–34.PubMedGoogle Scholar
  53. 53.
    Mathavan VK, Arregui M, Davis C, Singh K, Patel A, Meacham J. Management of postgastric by-pass noninsulinoma pancreatogenous hypoglycemia. Surg Endosc. 2010;24:2547–55.PubMedCrossRefGoogle Scholar
  54. 54.
    Rumilla KM, Erickson LA, Service FJ, et al. Hyperinsulinemic hypoglycemia with nesidioblastosis: histological features and growth factor expression. Mod Pathol. 2009;22:239–45.PubMedCrossRefGoogle Scholar
  55. 55.
    Ritz P, Hanaire H. Post-bypass hypoglycemia: a review of current findings. Diabetes Metab. 2011;37:274–81.PubMedCrossRefGoogle Scholar

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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Glauco da Costa Alvarez
    • 1
  1. 1.Department of SurgeryFederal University of Santa MariaSanta MariaBrazil

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