Elsevier

Surgery for Obesity and Related Diseases

Volume 8, Issue 5, September–October 2012, Pages 641-647
Surgery for Obesity and Related Diseases

Review article
Algorithm to diagnose etiology of hypoglycemia after Roux-en-Y gastric bypass for morbid obesity: case series and review of the literature

https://doi.org/10.1016/j.soard.2011.08.008Get rights and content

Abstract

Background

Gastric bypass is a proven treatment option for weight loss and the reduction of medical co-morbid conditions in the obese population. Severe refractory and/or recurrent hypoglycemia can occur, especially in postoperative patients who do not comply with the guidelines for oral glucose consumption. In a very small number of patients, the cause is not dietary indiscretions but, instead, factitious insulin administration or nesidioblastosis. The optimal evaluation and management for these diagnoses is not completely lucid yet important for bariatric surgeons and physicians alike to be familiar. Our objectives were to review the appropriate evaluation and treatment options for etiologies of hypoglycemia after gastric bypass and to create an algorithm that biochemically assesses the etiology of hypoglycemia. The setting was a university hospital in the United States.

Methods

We present the cases of 3 patients who developed symptomatic hypoglycemia from distinct etiologies after laparoscopic Roux-en-Y gastric bypass. We also reviewed the current data regarding diagnosis and treatment.

Results

Each patient's evaluation and management is elaborated in detail. We propose a novel algorithm for the biochemical evaluation of hypoglycemia after gastric bypass according to our experience and the review of the literature.

Conclusion

Most cases of symptomatic hypoglycemia that develop in gastric bypass patients are associated with dietary indiscretions. However, a small subset of patients can develop refractory, recurrent, hyperinsulinemic hypoglycemia from factitious insulin administration or nesidioblastosis.

Section snippets

Methods

Permission was granted to review the postoperative outcomes and related data from the patients included in the present series from the Duke University institutional review board from our prospectively maintained bariatric surgery database. In the present report, we describe 3 distinct cases of hypoglycemia occurring after LRYGB.

Case 1

A 61-year-old woman was seen in the bariatric clinic for monitoring of weight loss and screening for possible medical complications 2 years after LRYGB. She reported neuroglycopenic symptoms (i.e., lethargy, loss of focus, and malaise) that required a visit to the emergency department and that had resolved with oral glucose treatment but recurred the following day. She denied any use of insulin or oral diabetes medications, and her dietary history failed to demonstrate any excess carbohydrate

Discussion

We report 3 significant cases of hypoglycemia after LRYGB. The expanding MO population in the United States has led to a robust increase in surgery for weight loss and the reduction of co-morbid conditions. In turn, LRYGB has been the primary bariatric procedure of choice owing to its consistent reduction of excess weight and the long-term data supporting its lasting effect and lower wound-related complications compared with open RYGB [18], [19]. Clinically significant hypoglycemia after

Conclusion

Although hypoglycemia after RYGB is not a particularly common complication of the most common primary bariatric procedure, the differential diagnosis varies. The bariatric surgeon must consider the following etiologies when evaluating hypoglycemia: dumping syndrome, factitious insulin use, and nesidioblastosis. A thorough and systematic evaluation, including history, serum biochemical analysis, and diagnostic testing, can distinguish these diagnoses. We have suggested a novel algorithm to

Disclosures

D. D. Portenier received research support and honorarium as a proctor for Allergan and research support and honorarium as a speaker for, and consultant to, Covidien. The remaining authors have no commercial associations that might be a conflict of interest in relation to this article.

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