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Clinical Overview > Condition/ Syndrome > Post-prandial hypoglycaemia

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Xin Chen Division of Internal Medicine, LAC+USC Medical Center, University of Southern California, Los Angeles, California, USA

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Dina Kamel Division of Endocrinology, Diabetes, and Metabolism, Keck School of Medicine, LAC+USC Medical Center, University of Southern California, Los Angeles, California, USA

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Braden Barnett Division of Endocrinology, Diabetes, and Metabolism, Keck School of Medicine, LAC+USC Medical Center, University of Southern California, Los Angeles, California, USA

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Evan Yung Division of Pathology, LAC+USC Medical Center, University of Southern California, Los Angeles, California, USA

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Adrienne Quinn Keck School of Medicine, University of Southern California, Los Angeles, California, USA

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Caroline Nguyen Division of Endocrinology, Diabetes, and Metabolism, Keck School of Medicine, LAC+USC Medical Center, University of Southern California, Los Angeles, California, USA

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Summary

There has been an increasing awareness of post gastric bypass hypoglycemia (PGBH). Histopathologic findings from such patients who underwent partial/total pancreatomy, however, can vary widely from minimal changes to classic nesidioblastosis, making the pathologic diagnosis challenging. PGBH typically presents as postprandial hypoglycemia, as opposed to insulinoma, which presents as fasting hypoglycemia. Herein, we describe an unusual case of a patient with PGBH who initially presented with postprandial hypoglycemia three years after surgery, but later developed fasting hyperinsulinemic hypoglycemia as the disease progressed. Our hypothesis for this phenomenon is that this disease is progressive, and later in its course, the insulin release becomes dissociated from food stimulation and is increased at baseline. Future studies are needed to investigate the prevalence as well as etiology of this progression from postprandial to fasting hypoglycemia.

Learning points:

  • There has been an increasing awareness of post gastric bypass hypoglycemia (PGBH).

  • Histopathologically, PGBH can vary from minimal changes to nesidioblastosis.

  • Although uncommon, patients with PGBH after Roux-en-Y gastric bypass may present with both postprandial and fasting hyperinsulinemic hypoglycemia as disease progresses.

  • Our hypothesis for this phenomenon is that the insulin release becomes dissociated from food stimulation and is increased at baseline with disease progression.

Taxonomy:
Clinical Overview, Gland/Organ, Pancreas, Topic, Obesity, Hormone, Insulin, Condition/ Syndrome, Hyperinsulinaemic hypoglycaemia, Hypoglycaemia, Iatrogenic disorder, Post-prandial hypoglycaemia, Patient Demographics, Age, Adult, Gender, Female, Ethnicity, White, Country of Treatment, United States, Diagnosis and Treatment, Signs and Symptoms, Dizziness, Hyperhidrosis, Hyperinsulinaemia, Hypoglycaemia, Syncope, Tremulousness, Investigation, C-peptide (blood), Glucose (blood), Glucose (blood, fasting), Haematoxylin and eosin staining, Histopathology, Immunohistochemistry, Insulin, Intervention, Bariatric surgery, Diet, Pancreatectomy, Medication, Acarbose, Alpha-glucosidase inhibitors, Diazoxide, Octreotide, Somatostatin analogues, Publication Details, Case Report Type, Unique/unexpected symptoms or presentations of a disease
DOI:
https://doi.org/10.1530/EDM-18-0089
Volume/Issue:
Volume 2018: Issue 1
Open access
Sarah Y Qian Department of Endocrinology and Diabetes, The Alfred Hospital, Melbourne, Australia

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Matthew J L Hare Department of Endocrinology and Diabetes, The Alfred Hospital, Melbourne, Australia

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Alan Pham Department of Anatomical Pathology, The Alfred Hospital, Melbourne, Australia

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Duncan J Topliss Department of Endocrinology and Diabetes, The Alfred Hospital, Melbourne, Australia
Department of Medicine, Monash University, Melbourne, Australia

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Summary

Insulinomas are rare neuroendocrine tumours that classically present with fasting hypoglycaemia. This case report discusses an uncommon and challenging case of insulinoma soon after upper gastrointestinal surgery. A 63-year-old man presented with 6 months of post-prandial hypoglycaemia beginning after a laparoscopic revision of Toupet fundoplication. Hyperinsulinaemic hypoglycaemia was confirmed during a spontaneous episode and in a mixed-meal test. Localisation studies including magnetic resonance imaging (MRI), endoscopic ultrasound (EUS) and gallium dotatate positron emission tomography (68Ga Dotatate PET) were consistent with a small insulinoma in the mid-body of the pancreas. The lesion was excised and histopathology was confirmed a localised well-differentiated neuroendocrine pancreatic neoplasm. There have been no significant episodes of hypoglycaemia since. This case highlights several key points. Insulinoma should be sought in proven post-prandial hyperinsulinaemic hypoglycaemia – even in the absence of fasting hypoglycaemia. The use of nuclear imaging targeting somatostatin and GLP1 receptors has improved accuracy of localisation. Despite these advances, accurate surgical resection can remain challenging.

Learning points:

  • Hypoglycaemia is defined by Whipple’s triad and can be provoked by fasting or mixed-meal tests.

  • Although uncommon, insulinomas can present with post-prandial hypoglycaemia.

  • In hypoglycaemia following gastrointestinal surgery (i.e. bariatric surgery or less commonly Nissen fundoplication) dumping syndrome or non-insulinoma pancreatogenous hypoglycaemia syndrome (NIPHS) should be considered.

  • Improved imaging techniques including MRI, endoscopic ultrasound and functional nuclear medicine scans aid localisation of insulinomas.

  • Despite advances in imaging and surgical techniques, accurate resection of insulinomas remains challenging.

Taxonomy:
Clinical Overview, Gland/Organ, Pancreas, Topic, Endocrine-related cancer, Hormone, Insulin, Condition/ Syndrome, Hyperinsulinaemic hypoglycaemia, Hypoglycaemia, Insulinoma, Neuroendocrine tumour, Pancreatic neuroendocrine tumour, Post-prandial hypoglycaemia, Patient Demographics, Age, Adult, Gender, Male, Ethnicity, White, Country of Treatment, Australia, Diagnosis and Treatment, Signs and Symptoms, Concentration difficulties, Confusion, Hyperhidrosis, Hyperinsulinaemia, Hypoglycaemia, Tremulousness, Investigation, Chromogranin A, C-peptide (blood), CT scan, Glucose (blood, postprandial), Glucose tolerance (oral), Histopathology, Immunohistochemistry, Insulin, MRI, PET scan, Synaptophysin, Ultrasound scan, Intervention, Laparoscopy, Pancreatectomy, Resection of tumour, Related Disciplines, General practice, Oncology, Publication Details, Case Report Type, Unique/unexpected symptoms or presentations of a disease
DOI:
https://doi.org/10.1530/EDM-17-0131
Volume/Issue:
Volume 2018: Issue 1
Open access