1
|
Jalleh RJ, Jones KL, Islam MS, Cai L, Horowitz M. Surgical or medical treatment of obesity-associated type 2 diabetes-an increasing clinical conundrum. World J Diabetes 2024; 15:2036-2040. [DOI: 10.4239/wjd.v15.i10.2036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2024] [Revised: 09/09/2024] [Accepted: 09/14/2024] [Indexed: 09/26/2024] Open
Abstract
In this editorial, we comment on the article by He et al, specifically in relation to the efficacy of bariatric surgery vs glucagon-like peptide-1 receptor agonist (GLP-1RA) therapy in the management of type 2 diabetes (T2D) associated with obesity. Bariatric surgery has now also been shown to be safe and effective in pre-teens and teenagers with obesity and T2D, but information on newer GLP-1RAs in these groups is predictably limited. In older individuals (age > 65 years), both bariatric surgery and GLP-1RA therapy improve cardiovascular outcomes. Bariatric surgery is not infrequently associated with post-operative postprandial hypoglycemia, which is not the case with GLP-1RAs and, paradoxically, there is evidence that GLP-1RAs may reduce both the frequency and severity of postprandial hypoglycemia. Comparative trials of the long-term efficacy of bariatric surgery and GLP-1RAs are indicated.
Collapse
Affiliation(s)
- Ryan J Jalleh
- Adelaide Medical School and Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide; and Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide 5000, South Australia, Australia
| | - Karen L Jones
- Adelaide Medical School and Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide; and Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide 5000, South Australia, Australia
| | - Md Shahidul Islam
- Department of Biochemistry, School of Life Sciences, University of KwaZulu-Natal, Durban 4000, KwaZulu-Natal, South Africa
| | - Lu Cai
- Pediatric Research Institute, Departments of Pediatrics, Radiation Oncology, Phar-macology and Toxicology, University of Louisville, Wendy Novak Diabetes Institute, Norton Children’s Hospital, Louisville, KY 40202, United States
| | - Michael Horowitz
- Adelaide Medical School and Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide; and Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide 5000, South Australia, Australia
| |
Collapse
|
2
|
Jalleh RJ, Jones KL, Rayner CK, Marathe CS, Wu T, Horowitz M. Normal and disordered gastric emptying in diabetes: recent insights into (patho)physiology, management and impact on glycaemic control. Diabetologia 2022; 65:1981-1993. [PMID: 36194250 PMCID: PMC9630190 DOI: 10.1007/s00125-022-05796-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/01/2022] [Indexed: 01/19/2023]
Abstract
Gastric emptying is a major determinant of postprandial blood glucose, accounting for ~35% of variance in peak glucose in both healthy individuals and those with type 2 diabetes. Gastric emptying is frequently disordered in individuals with diabetes (both abnormally delayed and accelerated). Delayed gastric emptying, i.e. diabetic gastroparesis, may be linked to upper gastrointestinal symptoms for which current treatment remains suboptimal; pharmacological acceleration of delayed emptying is only weakly associated with symptom improvement. Accordingly, the relationship between symptoms and delayed gastric emptying is not simply 'cause and effect'. In insulin-treated patients, disordered gastric emptying, even when not associated with gastrointestinal symptoms, can cause a mismatch between the onset of insulin action and the availability of absorbed carbohydrate, leading to suboptimal glycaemic control. In patients with type 2 diabetes, interventions that slow gastric emptying, e.g. glucagon-like peptide-1 receptor agonists, reduce postprandial blood glucose. This review focuses on recent insights into the impact of gastric emptying on postprandial blood glucose, effects of diabetes therapy on gastric emptying and the management of disordered gastric emptying in diabetes. In view of the broad relevance of gastric emptying to diabetes management, it is important that future clinical trials evaluating novel therapies that may affect gastric emptying should quantify the latter with an appropriate technique, such as scintigraphy or a stable isotope breath test.
Collapse
Affiliation(s)
- Ryan J Jalleh
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Karen L Jones
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Christopher K Rayner
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia
| | - Chinmay S Marathe
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Tongzhi Wu
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
| | - Michael Horowitz
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia.
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia.
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia.
| |
Collapse
|
3
|
Mediators of Amylin Action in Metabolic Control. J Clin Med 2022; 11:jcm11082207. [PMID: 35456307 PMCID: PMC9025724 DOI: 10.3390/jcm11082207] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/08/2022] [Accepted: 04/13/2022] [Indexed: 02/06/2023] Open
Abstract
Amylin (also called islet amyloid polypeptide (IAPP)) is a pancreatic beta-cell hormone that is co-secreted with insulin in response to nutrient stimuli. The last 35 years of intensive research have shown that amylin exerts important physiological effects on metabolic control. Most importantly, amylin is a physiological control of meal-ending satiation, and it limits the rate of gastric emptying and reduces the secretion of pancreatic glucagon, in particular in postprandial states. The physiological effects of amylin and its analogs are mediated by direct brain activation, with the caudal hindbrain playing the most prominent role. The clarification of the structure of amylin receptors, consisting of the calcitonin core receptor plus receptor-activity modifying proteins, aided in the development of amylin analogs with a broad pharmacological profile. The general interest in amylin physiology and pharmacology was boosted by the finding that amylin is a sensitizer to the catabolic actions of leptin. Today, amylin derived analogs are considered to be among the most promising approaches for the pharmacotherapy against obesity. At least in conjunction with insulin, amylin analogs are also considered important treatment options in diabetic patients, so that new drugs may soon be added to the only currently approved compound pramlintide (Symlin®). This review provides a brief summary of the physiology of amylin’s mode of actions and its role in the control of the metabolism, in particular energy intake and glucose metabolism.
Collapse
|
4
|
Kandel D, Bojsen-Møller KN, Svane MS, Samkani A, Astrup A, Holst JJ, Madsbad S, Krarup T. Mechanisms of action of a carbohydrate-reduced, high-protein diet in reducing the risk of postprandial hypoglycemia after Roux-en-Y gastric bypass surgery. Am J Clin Nutr 2019; 110:296-304. [PMID: 30624666 DOI: 10.1093/ajcn/nqy310] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/11/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Postprandial hypoglycemia is a risk after Roux-en-Y gastric bypass (RYGB). OBJECTIVES We speculated that a carbohydrate-reduced, high-protein (CRHP) diet might reduce the risk of hypoglycemia and therefore compared the acute effects of a conventionally recommended (CR) diet and CRHP diet [55/30 energy percent (E%) carbohydrate and 15/30 E% protein, respectively] in RYGB patients. METHODS Ten individuals (2 males, 8 females, mean ± SD age 47 ± 7 y; stable body mass index 31 ± 6 kg/m2; 6 ± 3 y post-RYGB) with recurrent postprandial hypoglycemia documented by plasma glucose (PG) ≤3.4 mmol/L were examined on 2 d with isoenergetic CRHP or CR diets comprising a breakfast and subsequent lunch meal. RESULTS Peak PG was significantly reduced on the CRHP diet after breakfast and lunch by 11% and 31% compared with the CR diet. Nadir PG increased significantly on CRHP (by 13% and 9%). Insulin secretion was reduced, and glucagon secretion increased on the CRHP diet after both meals. Glucagon-like peptide 1 and glucose-dependent insulinotropic polypeptide secretion were lower after lunch but unaltered after breakfast on CRHP; β-cell function and insulin clearance were unchanged. CONCLUSIONS The CRHP diet lowered glucose excursions and reduced insulin secretion and incretin hormone responses, but enhanced glucagon responses compared with the CR diet. Taken together, the results may explain the decreased glucose variability and lower risk of postprandial hypoglycemia. This study was registered at clinicaltrials.gov as NCT02665715.
Collapse
Affiliation(s)
- Daniel Kandel
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | | | - Maria Saur Svane
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Amirsalar Samkani
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Arne Astrup
- Department of Nutrition, Exercise and Sports
| | - Jens J Holst
- Endocrinology Research Section, Department of Biomedical Sciences
- Section for Translational Physiology, Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Sten Madsbad
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Thure Krarup
- Department of Endocrinology, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| |
Collapse
|
5
|
Brix JM, Kopp HP, Höllerl F, Schernthaner GH, Ludvik B, Schernthaner G. Frequency of Hypoglycaemia after Different Bariatric Surgical Procedures. Obes Facts 2019; 12:397-406. [PMID: 31234171 PMCID: PMC6758723 DOI: 10.1159/000493735] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 09/14/2018] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES The frequency of postprandial hypoglycaemia after different operative procedures of bariatric surgery (BS) is unknown, although this complication is potentially dangerous. Predictors and severity of hypoglycaemia after Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy, and gastric banding were investigated in a large prospective study. METHODS This study was performed at an excellence centre for BS at a tertiary care institution. Data of 333 patients (mean BMI: 44.9 ± 9.6 kg/m2; mean age: 40 ± 10 years; 80.7% women) were analysed in a prospective study with a 2-year observation period after BS. All patients underwent a 2-hour oral glucose tolerance test (OGTT) with measurements of blood glucose (BG) and insulin. For the purpose of this study, hypoglycaemia was defined as a post-challenge BG <2.8 mmol/L during the OGTT. RESULTS 72 (25.6%) of 281 patients showed post-challenge hypoglycaemia after surgery. Hypoglycaemia was different after various procedures: 32.6% of patients after RYGB, 22.6% after sleeve gastrectomy, but only 2.3% after gastric banding had hypoglycaemia. In the whole group, patients with hypoglycaemia had lost more weight (p = 0.013), had a slightly greater decrease in BMI (p = 0.037), a greater change in 2-hour post-challenge BG (p = 0.001), and a smaller change in 1-hour post-challenge insulin (p = 0.004) compared to patients without hypoglycaemia. CONCLUSION This prospective study shows a higher prevalence of severe hypoglycaemia (25.6%) after BS than anticipated from retrospective registers. A systematic evaluation of glucose and insulin levels by OGTT 2 years post-surgery may help to identify patients at increased risk for symptomatic and asymptomatic hypoglycaemia.
Collapse
Affiliation(s)
- Johanna Maria Brix
- Department of Medicine I, Rudolfstiftung Hospital Vienna, Vienna, Austria
- Karl Landsteiner Institute for Obesity and Metabolism, Vienna, Austria
| | - Hans-Peter Kopp
- Department of Medicine I, Rudolfstiftung Hospital Vienna, Vienna, Austria
- Karl Landsteiner Institute for Obesity and Metabolism, Vienna, Austria
| | - Florian Höllerl
- Department of Medicine I, Rudolfstiftung Hospital Vienna, Vienna, Austria
- Karl Landsteiner Institute for Obesity and Metabolism, Vienna, Austria
| | | | - Bernhard Ludvik
- Department of Medicine I, Rudolfstiftung Hospital Vienna, Vienna, Austria,
- Karl Landsteiner Institute for Obesity and Metabolism, Vienna, Austria,
| | | |
Collapse
|
6
|
Nor Hanipah Z, Punchai S, Birriel TJ, Lansang MC, Kashyap SR, Brethauer SA, Schauer PR, Aminian A. Clinical features of symptomatic hypoglycemia observed after bariatric surgery. Surg Obes Relat Dis 2018; 14:1335-1339. [DOI: 10.1016/j.soard.2018.02.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 02/19/2018] [Accepted: 02/20/2018] [Indexed: 01/10/2023]
|
7
|
Salinari S, Mingrone G, Bertuzzi A, Previti E, Capristo E, Rubino F. Downregulation of Insulin Sensitivity After Oral Glucose Administration: Evidence for the Anti-Incretin Effect. Diabetes 2017; 66:2756-2763. [PMID: 28851712 DOI: 10.2337/db17-0234] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 08/21/2017] [Indexed: 11/13/2022]
Abstract
Intestinal nutrients stimulate insulin secretion more potently than intravenous (IV) glucose administration under similar plasma glucose levels (incretin effect). According to the anti-incretin theory, intestinal nutrients should also cause a reduction of insulin sensitivity and/or secretion (anti-incretin effect) to defend against hyperinsulinemia-hypoglycemia. An exaggerated anti-incretin effect could contribute to insulin resistance/type 2 diabetes, whereas reduction of anti-incretin signals might explain diabetes improvement after bariatric surgery. In this study, we tested some of the predictions made by the anti-incretin theory. Eight healthy volunteers and eight severely obese subjects with insulin resistance were studied. Insulin secretion, insulin sensitivity, Ra, and disposition index were measured after oral glucose tolerance test and isoglycemic IV glucose injection (IGIV). Obese subjects were studied before and after intestinal bypass surgery (biliopancreatic diversion [BPD]). The d-xylose test and lactulose-to-rhamnose ratio were used to test for possible malabsorption of glucose after surgery. Monte Carlo mathematical simulations were used to test whether insulin secretion induced by oral glucose could cause hypoglycemia when coupled with the levels of insulin sensitivity measured during IGIV. Despite isoglycemic conditions, insulin sensitivity was lower during oral than during IV glucose administration. This difference was amplified in obese subjects and reduced to normal after BPD. No evidence of glucose malabsorption was found. Mathematical simulations showed that hypoglycemia would occur if insulin sensitivity were not reduced by oral glucose stimulation. This study demonstrates an anti-incretin effect of intestinal glucose stimulation, which downregulates insulin sensitivity. The findings support a new model for how foodborne factors can induce insulin-resistance and provide a possible explanation for the improvement of insulin resistance/diabetes after gastrointestinal bypass surgery.
Collapse
Affiliation(s)
- Serenella Salinari
- Department of Computer, Control, and Management Engineering, University of Rome "La Sapienza," Rome, Italy
| | - Geltrude Mingrone
- Department of Internal Medicine, Catholic University of the Sacred Heart, Rome, Italy
- Diabetes and Nutritional Sciences, King's College London, London, U.K
| | - Alessandro Bertuzzi
- Institute of Systems Analysis and Computer Science, National Research Council, Rome, Italy
| | - Elena Previti
- Department of Computer, Control, and Management Engineering, University of Rome "La Sapienza," Rome, Italy
| | - Esmeralda Capristo
- Department of Internal Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Rubino
- Diabetes and Nutritional Sciences, King's College London, London, U.K.
- Department of Metabolic and Bariatric Surgery, King's College London and King's College Hospital, London, U.K
| |
Collapse
|
8
|
Mordes JP, Alonso LC. Evaluation, Medical Therapy, and Course of Adult Persistent Hyperinsulinemic Hypoglycemia After Roux-en-Y Gastric Bypass Surgery: A Case Series. Endocr Pract 2016; 21:237-46. [PMID: 25100376 DOI: 10.4158/ep14118.or] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the evaluation and treatment of hyperinsulinemic hypoglycemia in adults who had undergone gastric bypass surgery. A small number of patients who undergo Roux-en-Y bypass surgery develop postprandial hypoglycemia in the absence of dumping. In some cases, such patients have been treated with pancreatectomy. METHODS We report the demographics, diagnostic results, response to medical therapy, and subsequent course of 6 referral patients with post-Roux-en-Y gastric bypass hypoglycemia. RESULTS Characteristic clinical and metabolic parameters consistent with hyperinsulinemic hypoglycemia were identified. Parameters were similar for both spontaneous and glucose-challenge-induced hypoglycemia. In the context of exclusively postprandial symptoms, simultaneous glucose ≤55 mg/dL, insulin ≥17 μU/mL, C peptide ≥3.0 ng/mL, and insulin to glucose ratio >0.3 were associated with Roux-en-Y gastric bypass hyperinsulinemic hypoglycemia. Five of 6 patients improved on therapy consisting of dietary modification plus either calcium channel blockade, acarbose, or both. Two patients have remained on therapy for 12 to 15 months. The nonresponder was atypical and had had hypoglycemic events for several decades. Three treated patients were subsequently observed to have undergone partial or complete remission from hypoglycemic episodes after 2 to 37 months of therapy. None of the 6 have undergone pancreatectomy, and none have evidence of insulinoma. Invasive diagnostic procedures were of limited utility. CONCLUSION In a subset of patients with post-Roux-en-Y gastric bypass hyperinsulinemic hypoglycemia, medical management can be efficacious and an alternative to partial pancreatectomy. In some cases, the disorder remits spontaneously.
Collapse
Affiliation(s)
- John P Mordes
- Department of Medicine, Division of Endocrinology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Laura C Alonso
- Division of Diabetes, University of Massachusetts Medical School, Worcester, Massachusetts
| |
Collapse
|
9
|
Vilarrasa N, Goday A, Rubio MA, Caixàs A, Pellitero S, Ciudin A, Calañas A, Botella JI, Bretón I, Morales MJ, Díaz-Fernández MJ, García-Luna PP, Lecube A. Hyperinsulinemic Hypoglycemia after Bariatric Surgery: Diagnosis and Management Experience from a Spanish Multicenter Registry. Obes Facts 2016; 9:41-51. [PMID: 26901345 PMCID: PMC5644871 DOI: 10.1159/000442764] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 11/24/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Severe postprandial hypoglycemia after bariatric surgery is a rare but invalidating complication. Our aim was to describe the different tests performed for its diagnosis and their outcomes as well as the response to the prescribed pharmacological and surgical treatments. METHODS Multicenter, retrospective systematic review of cases with recurrent severe postprandial hypoglycemia. RESULTS Over 11 years of follow-up, 22 patients were identified. The test most used to provoke hypoglycemia was the oral glucose load test followed by the mixed meal test which was the least standardized test. With pharmacological treatment, 3 patients were symptom-free (with octreotide) and in 12 patients hypoglycemic episodes were attenuated. Seven patients had persistent hypoglycemic episodes and underwent surgery. Partial pancreatectomy was performed in 3 patients who had positive selective arterial calcium stimulation, and nesidioblastosis was confirmed in 2 patients. Reconversion to normal anatomy was performed in 3 patients, and 1 patient underwent a resection of the 'candy cane' roux limb, with resolution of hypoglycemia in all cases. CONCLUSIONS There is high heterogeneity in the evaluation and treatment options for postoperative hypoglycemia. In patients that do not respond to pharmacological treatment, reconstruction of gastrojejunal continuity may be the safest and most successful procedure.
Collapse
Affiliation(s)
- Nuria Vilarrasa
- Department of Endocrinology and Nutrition, Hospital Universitario de Bellvitge-IDIBELL, Lx00B4;Hospitalet de Llobregat, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Metabolic consequences of the incorporation of a Roux limb in an omega loop (mini) gastric bypass: evaluation by a glucose tolerance test at mid-term follow-up. Surg Endosc 2015; 30:2935-45. [DOI: 10.1007/s00464-015-4581-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 09/19/2015] [Indexed: 01/08/2023]
|
11
|
Lee CJ, Clark JM, Schweitzer M, Magnuson T, Steele K, Koerner O, Brown TT. Prevalence of and risk factors for hypoglycemic symptoms after gastric bypass and sleeve gastrectomy. Obesity (Silver Spring) 2015; 23:1079-84. [PMID: 25866150 PMCID: PMC4414701 DOI: 10.1002/oby.21042] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 01/06/2015] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine the prevalence of and risk factors for postprandial hypoglycemic symptoms among bariatric surgery patients. METHODS A questionnaire including the Edinburgh hypoglycemia scale was mailed to patients who underwent either Roux-en-Y gastric bypass (RYGB) or vertical sleeve gastrectomy (VSG) at a single center. Based on the questionnaire, the patients were categorized as having high or low suspicion for post surgical, postprandial hypoglycemic symptoms. RESULTS Of the 1119 patients with valid addresses, 40.2% (N = 450) responded. Among the respondents, 34.2% had a high suspicion for symptoms of post bariatric surgery hypoglycemia. In multivariate analyses, in addition to female sex (P = 0.001), RYGB (P = 0.004), longer time since surgery (P = 0.013), and lack of diabetes (P = 0.040), the high suspicion group was more likely to report pre-operative symptoms of hypoglycemia (P < 0.001), compared to the low suspicion group. Similar results were observed when the high suspicion group was restricted to those requiring assistance from others, syncope, seizure with severe symptoms, or medically confirmed hypoglycemia (N = 52). CONCLUSIONS One third of patients who underwent RYGB or VSG reported postprandial symptoms concerning for postsurgical hypoglycemia, which was related to the presence of pre-operative hypoglycemic symptoms. Pre-operative screening for hypoglycemic symptoms may identify a group of patients at increased risk of postbariatric surgery hypoglycemia.
Collapse
Affiliation(s)
- Clare J. Lee
- Division of Endocrinology, Diabetes and Metabolism, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Jeanne M. Clark
- Department of Medicine, Division of General Internal Medicine, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Michael Schweitzer
- Department of Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Thomas Magnuson
- Department of Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Kimberley Steele
- Department of Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Todd T. Brown
- Division of Endocrinology, Diabetes and Metabolism, The Johns Hopkins University, Baltimore, Maryland, USA
| |
Collapse
|
12
|
Woo CY, Jeong JY, Jang JE, Leem J, Jung CH, Koh EH, Lee WJ, Kim MS, Park JY, Lee JB, Lee KU. Clinical features and causes of endogenous hyperinsulinemic hypoglycemia in Korea. Diabetes Metab J 2015; 39:126-31. [PMID: 25922806 PMCID: PMC4411543 DOI: 10.4093/dmj.2015.39.2.126] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 07/24/2014] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Endogenous hyperinsulinemic hypoglycemia (EHH) is characterized by an inappropriately high plasma insulin level, despite a low plasma glucose level. Most of the EHH cases are caused by insulinoma, whereas nesidioblastosis and insulin autoimmune syndrome (IAS) are relatively rare. METHODS To evaluate the relative frequencies of various causes of EHH in Korea, we retrospectively analyzed 84 patients who were diagnosed with EHH from 1998 to 2012 in a university hospital. RESULTS Among the 84 EHH patients, 74 patients (88%), five (6%), and five (6%) were diagnosed with insulinoma, nesidioblastosis or IAS, respectively. The most common clinical manifestation of EHH was neuroglycopenic symptoms. Symptom duration before diagnosis was 14.5 months (range, 1 to 120 months) for insulinoma, 1.0 months (range, 6 days to 7 months) for nesidioblastosis, and 2.0 months (range, 1 to 12 months) for IAS. One patient, who was diagnosed with nesidioblastosis in 2006, underwent distal pancreatectomy but was later determined to be positive for insulin autoantibodies. Except for one patient who was diagnosed in 2007, the remaining three patients with nesidioblastosis demonstrated severe hyperinsulinemia (157 to 2,719 µIU/mL), which suggests that these patients might have had IAS, rather than nesidioblastosis. CONCLUSION The results of this study suggest that the prevalence of IAS may be higher in Korea than previously thought. Therefore, measurement of insulin autoantibody levels is warranted for EHH patients, especially in patients with very high plasma insulin levels.
Collapse
Affiliation(s)
- Chang-Yun Woo
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Yun Jeong
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Eun Jang
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Jaechan Leem
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Hee Jung
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Hee Koh
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Woo Je Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Seon Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Joong-Yeol Park
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Bok Lee
- Department of Statistics, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Up Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
13
|
Cotugno M, Nosso G, Saldalamacchia G, Vitagliano G, Griffo E, Lupoli R, Angrisani L, Riccardi G, Capaldo B. Clinical efficacy of bariatric surgery versus liraglutide in patients with type 2 diabetes and severe obesity: a 12-month retrospective evaluation. Acta Diabetol 2015; 52:331-6. [PMID: 25218924 DOI: 10.1007/s00592-014-0644-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 08/25/2014] [Indexed: 12/22/2022]
Abstract
AIMS To evaluate the clinical efficacy of bariatric surgery vs medical therapy with liraglutide on weight loss, glycemic control and cardiovascular risk profile in patients with type 2 diabetes and severe obesity. METHODS A retrospective evaluation was conducted in 31 patients with type 2 diabetes and severe obesity who had undergone bariatric surgery and in 31 patients with type 2 diabetes and comparable body weight who had added liraglutide to their background medical treatment in the period 2009-2013. Anthropometric parameters, glycemic control, treatment of diabetes and other comorbidities, safety and side effects before and 12 months after treatment were assessed. RESULTS Age was 47 ± 8 years (mean ± SD) in bariatric surgery and 56 ± 9 years in medical treatment group (p < 0.001); body mass index before treatment was 44 ± 7 and 40 ± 4 kg/m(2) in bariatric surgery and medical treatment, respectively (p = 0.03). Twelve months after treatment, average weight loss was 38 ± 15 kg among bariatric surgery patients, and 5 ± 8 kg in medical treatment group (p < 0.001). Glycemic control improved in both groups with greater improvement in bariatric surgery patients. The UKPDS risk score decreased in both groups, although it remained higher in medical treatment than in bariatric surgery patients (p < 0.001). Of note, almost 60 % of patients on liraglutide met the target of glycated hemoglobin <7 % (53 mmol/mol) and lost ≥5 % of body weight. CONCLUSIONS In severely obese type 2 diabetic patients, bariatric surgery reduced body weight and improved overall metabolic control to a greater extent than medical treatment. Randomized clinical studies are necessary.
Collapse
Affiliation(s)
- M Cotugno
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Via S. Pansini, 5, 80131, Naples, Italy
| | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Abstract
Bariatric surgery is the most effective therapeutic option for obese patients; however, it carries substantial risks, including procedure-related complications, malabsorption, and hormonal disturbance. Recent years have seen an increase in the bariatric surgeries performed utilizing either an independent or a combination of restrictive and malabsorptive procedures. We review some complications of bariatric procedures more specifically, hypoglycemia and osteoporosis, the recommended preoperative assessment and then regular follow up, and the therapeutic options. Surgeon, internist, and the patient must be aware of the multiple risks of this kind of surgery and the needed assessment and follow up.
Collapse
Affiliation(s)
- Anwar A. Jammah
- Department of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia,Address for correspondence: Dr. Anwar A. Jammah, PO Box - 2925, Riyadh - 11461, Kingdom of Saudi Arabia. E-mail:
| |
Collapse
|
15
|
Martens P, Tits J. Approach to the patient with spontaneous hypoglycemia. Eur J Intern Med 2014; 25:415-21. [PMID: 24641805 DOI: 10.1016/j.ejim.2014.02.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Revised: 02/27/2014] [Accepted: 02/28/2014] [Indexed: 12/18/2022]
Abstract
UNLABELLED Hypoglycemia is common in daily clinical practice and often occurs during the treatment of diabetes mellitus. However, a small minority of hypoglycemia encountered in clinical practice is spontaneous and thus not induced by glycemic lowering agents. These spontaneous hypoglycemic events confront the clinician with a diagnostic enigma. Although the trained clinician can recognize the autonomic and neuroglycopenic symptoms of hypoglycemia even in a patient not on insulin, it remains challenging to decipher the etiology of a spontaneous hypoglycemic event. A logical and stepwise approach to the spontaneous hypoglycemic event allows for a conclusive diagnosis. This diagnostic process consists of adequately diagnosing hypoglycemia by fulfilling Whipple's triad, stratifying patients according to their clinical status and analyzing a full hypoglycemic blood panel. A complete hypoglycemic blood panel should include the analysis of glucose, insulin, C-peptide, pro-insulin, insulin antibodies and the presence of oral hypoglycemic agents. For patients with episodes of hypoglycemia induced by excessive endogenous insulin, additional imaging is often required to detect the presence of an underlying insulinoma. By diagnosing the underlying cause of the spontaneous hypoglycemia, the physician also diagnosis the mechanism by which the hypoglycemic event occurs. Allowing for a problem orientated therapeutic approach. METHODOLOGY The present review is based upon a comprehensive PubMed search between 1985 and 2013. This uses search terms of spontaneous hypoglycemia, insulinoma, nesidioblastosis, insulin auto-immunity, noninsulinoma pancreatogenous hypoglycemia syndrome, hormone deficiency, pro-IGF II, and pro-insulin growth factor II, and cross reference searching of pivotal articles in the subject.
Collapse
Affiliation(s)
- Pieter Martens
- Department of Internal Medicine, University Hospital Gasthuisberg Leuven, KU Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Jos Tits
- Department of Endocrinology, Hospital Ziekenhuis Oost-Limburg ZOL, Genk, Belgium
| |
Collapse
|
16
|
Itariu BK, Zeyda M, Prager G, Stulnig TM. Insulin-like growth factor 1 predicts post-load hypoglycemia following bariatric surgery: a prospective cohort study. PLoS One 2014; 9:e94613. [PMID: 24736741 PMCID: PMC3988194 DOI: 10.1371/journal.pone.0094613] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 03/17/2014] [Indexed: 12/19/2022] Open
Abstract
Postprandial hypoglycemia is a complication following gastric bypass surgery, which frequently remains undetected. Severe hypoglycemic episodes, however, put patients at risk, e.g., for syncope. A major cause of hypoglycemia following gastric bypass is hyperinsulinemic nesidioblastosis. Since pancreatic islets in nesidioblastosis overexpress insulin-like growth factor 1 (IGF-1) receptor α and administration of recombinant IGF-1 provokes hypoglycemia, our main objective was to investigate the occurrence of post-load hypoglycemia one year after bariatric surgery and its relation to pre- and post-operative IGF-1 serum concentrations. We evaluated metabolic parameters including 2 h 75 g oral glucose tolerance test (OGTT) and measured IGF-1 serum concentration in thirty-six non-diabetic patients (29 f/7 m), aged 41.3±2.0 y with a median (IQR) BMI of 30.9 kg/m2 (27.5-34.3 kg/m2), who underwent elective bariatric surgery (predominantly gastric bypass, 83%) at our hospital. Post-load hypoglycemia as defined by a 2 h glucose concentration <60 mg/dl was detected in 50% of patients. Serum insulin and C-peptide concentration during the OGTT and HOMA-IR (homeostatic model assessment-insulin resistance) were similar in hypoglycemic and euglycemic patients. Strikingly, pre- and post-operative serum IGF-1 concentrations were significantly higher in hypoglycemic patients (p = 0.012 and p = 0.007 respectively). IGF-1 serum concentration before surgery negatively correlated with 2 h glucose concentration during the OGTT (rho = -0.58, p = 0.0003). Finally, IGF-1 serum concentrations before and after surgery significantly predicted post-load hypoglycemia with odds ratios of 1.28 (95%CI:1.03-1.55, p = 0.029) and 1.18 (95%CI:1.03-1.33, p = 0.015), respectively, for each 10 ng/ml increment. IGF-1 serum concentration could be a valuable biomarker to identify patients at risk for hypoglycemia following bariatric surgery independently of a diagnostic OGTT. Thus, IGF-1 testing could help to prevent a significant complication of gastric bypass surgery.
Collapse
Affiliation(s)
- Bianca K. Itariu
- Division of Endocrinology and Metabolism, Department of Medicine III, Medical University Vienna, Vienna, Austria
- Christian Doppler Laboratory for Cardio-Metabolic Immunotherapy, Medical University Vienna, Vienna, Austria
| | - Maximilian Zeyda
- Division of Endocrinology and Metabolism, Department of Medicine III, Medical University Vienna, Vienna, Austria
- Christian Doppler Laboratory for Cardio-Metabolic Immunotherapy, Medical University Vienna, Vienna, Austria
| | - Gerhard Prager
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas M. Stulnig
- Division of Endocrinology and Metabolism, Department of Medicine III, Medical University Vienna, Vienna, Austria
- Christian Doppler Laboratory for Cardio-Metabolic Immunotherapy, Medical University Vienna, Vienna, Austria
- * E-mail:
| |
Collapse
|
17
|
Mala T. Postprandial hyperinsulinemic hypoglycemia after gastric bypass surgical treatment. Surg Obes Relat Dis 2014; 10:1220-5. [PMID: 25002326 DOI: 10.1016/j.soard.2014.01.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 01/09/2014] [Accepted: 01/14/2014] [Indexed: 12/15/2022]
Abstract
An association between post-Roux-en-Y gastric bypass (RYGB) hypoglycemia and nesidioblastosis was reported in 2005 and may cause serious neuroglycopenic symptoms. Most patients with postprandial hypoglycemia after RYGB respond to nutritional and medical treatment. A subset of patients, however, may not respond adequately and surgery may be considered. This review describes the current experience with surgical intervention for severe post-RYGB hypoglycemia. PubMed and MEDLINE searches were made for reports describing clinical outcome after such surgery. Fourteen papers including 75 patients were identified. Different surgical interventions were applied including gastric tube placement, reversal of the bypass with and without concomitant sleeve resection, gastric pouch restriction, and pancreatic resection and reresection. Pancreatic resection was performed in 51 (68%) patients, 17 (23%) had RYGB reversal and eleven (15%) had gastric pouch restriction alone. Eight (11%) patients received 2 or more consecutive procedures for hypoglycemia and combined interventions were made in several patients. Resolution of the symptoms occurred in 34/51 (67%) patients after pancreatic resection, 13/17 (76%) after reversal, and 9/11 (82%) after pouch restriction. Mean follow up, however, was short for most series and the methods applied for evaluation of hypoglycemia varied. Weight regain, diabetes and recurrent symptoms were late complications. The optimal therapy for hypoglycemia after RYGB is not defined. Long-term evaluations and knowledge about the physiology of post-RYGB hypoglycemia, may enable therapy with improved control of the glucose excursions.
Collapse
Affiliation(s)
- Tom Mala
- Department of Morbid Obesity and Bariatric Surgery/Department of Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway.
| |
Collapse
|
18
|
Abstract
PURPOSE OF REVIEW Bariatric surgery has emerged as a highly effective treatment for obesity and is increasingly recognized to have benefits for glycemic management in patients with pre-existing type 2 diabetes mellitus (T2DM), and for diabetes prevention. This article will review the efficacy and mechanisms of metabolic surgery for the treatment of T2DM. RECENT FINDINGS Recent small randomized studies with 1-2 years of follow-up begin to provide level 1 data of the effects of surgical procedures compared to medical management on glycemic control. Physiology studies using sophisticated metabolic techniques to evaluate insulin secretion, action, and entero-endocrine changes in patients preoperatively and postoperatively have shed light on the mechanisms that lead to changes in glycemia observed after bariatric surgery. SUMMARY Understanding the efficacy and physiologic effects of bariatric surgery on metabolism will help guide patient management in the context of a growing epidemic of obesity and T2DM, and may also ultimately enable us to develop less invasive but equally effective therapeutic strategies for weight loss and metabolic control.
Collapse
Affiliation(s)
- Florencia Halperin
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | |
Collapse
|
19
|
Himpens J, Verbrugghe A, Cadière GB, Everaerts W, Greve JW. Long-term results of laparoscopic Roux-en-Y Gastric bypass: evaluation after 9 years. Obes Surg 2013; 22:1586-93. [PMID: 22865194 DOI: 10.1007/s11695-012-0707-z] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This retrospective study aimed to evaluate the long-term results of the laparoscopic Roux-en-Y gastric bypass (LRYGB) procedure performed at our department of bariatric surgery. The 126 consecutive patients treated by LRYGB between January 1, 2001 and December 31, 2002 were analyzed in August 2011. Seventy-seven patients (61.1 %), including 18 who had had previous bariatric surgery, were available for evaluation after 9.4 ± 0.6 years (range, 8.7-10.9 years). Eight patients (10.4 %) suffered from type 2 diabetes mellitus (DMII) at the time of surgery. Initial body mass index (BMI) was 40.3 ± 7.5 kg/m(2) (range, 24.5-66.1 kg/m(2)). There was no postoperative mortality, but two patients died of causes unrelated to the surgery. Some 9 % of the patients suffered from internal herniation, despite the closure of potential hernia sites. With time, the patients had the tendency to experience weight regain: percentage of excess BMI lost was 56.2 ± 29.3 % (range, -78.8 to 117.9 %), down from a maximum of 88.0 ± 29.6 % (range, -19.7 to 197.1 %), that had been obtained after a median of 2.0 years (range, 1-8 years). LRYGB was effective for diabetes control in 85.7 % of the affected patients, but, surprisingly, 27.9 % developed new-onset diabetes. The weight regain in this latter patient group was statistically not different from the nondiabetic group. Conversely, four patients required hospitalization for hypoglycemic syndrome. Two patients underwent reversal of their bypass for problems linked to glucose metabolism (one hypoglycemia, one DMII). Patient quality of life was fair. The patient satisfaction remained good in 76 % of the cases.
Collapse
|
20
|
Myint KS, Greenfield JR, Farooqi IS, Henning E, Holst JJ, Finer N. Prolonged successful therapy for hyperinsulinaemic hypoglycaemia after gastric bypass: the pathophysiological role of GLP1 and its response to a somatostatin analogue. Eur J Endocrinol 2012; 166:951-5. [PMID: 22408121 DOI: 10.1530/eje-11-1065] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Spontaneous hyperinsulinaemic hypoglycaemia following gastric bypass surgery (GBS) is increasingly recognised. However, its pathophysiology remains unclear. Some patients require pancreatectomy. Medical therapy with calcium channel blockers, acarbose and diazoxide has been reported to be beneficial but has variable adherence and response. METHOD We demonstrate the role of GLP1, counter-regulatory hormones and the subsequent response of GLP1 to somatostatin analogue therapy in a 42-year-old woman with persistent neuroglycopaenia 6 years after GBS. Plasma GLP1, insulin and glucose were measured for 5 h on three settings: i) a 75 g oral glucose tolerance test (OGTT); ii) a standard liquid test meal (LTM); and iii) an OGTT 30 min after a s.c. injection of 100 μg octreotide. RESULTS In comparison with obese non-diabetic controls, the patient had an elevated fasting and a markedly enhanced GLP1 response during the OGTT, followed by an exaggerated insulin response and a subsequent low glucose level. The GLP1 response to a LTM was similar but greater. Octreotide given prior to the OGTT attenuated both the GLP1 and insulin responses and abolished hypoglycaemia. Octreotide therapy significantly improved the patient's neuroglycopaenic symptoms. The hormone profile was reassessed after 6 months following the LTM preceded by octreotide injection. Peak GLP1 and insulin responses were less pronounced than pretreatment responses and without hypoglycaemia. The patient was treated with lanreotide and had remained symptom-free and euglycaemic for 4 years. CONCLUSION An exaggerated incretin response following altered gastrointestinal anatomy was the likely cause of hypoglycaemia in our GBS patient. Somatostatin successfully suppressed this response acutely and in the long term, thereby avoiding pancreatectomy and its sequelae.
Collapse
Affiliation(s)
- K S Myint
- Department of Endocrinology, Institute of Metabolic Science, Cambridge University NHS Trust, Cambridge CB2 0QQ, UK.
| | | | | | | | | | | |
Collapse
|
21
|
Jensen RT, Cadiot G, Brandi ML, de Herder WW, Kaltsas G, Komminoth P, Scoazec JY, Salazar R, Sauvanet A, Kianmanesh R. ENETS Consensus Guidelines for the management of patients with digestive neuroendocrine neoplasms: functional pancreatic endocrine tumor syndromes. Neuroendocrinology 2012; 95:98-119. [PMID: 22261919 PMCID: PMC3701449 DOI: 10.1159/000335591] [Citation(s) in RCA: 340] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
22
|
Valderas JP, Ahuad J, Rubio L, Escalona M, Pollak F, Maiz A. Acarbose Improves Hypoglycaemia Following Gastric Bypass Surgery Without Increasing Glucagon-Like Peptide 1 Levels. Obes Surg 2011; 22:582-6. [DOI: 10.1007/s11695-011-0581-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
|
23
|
Post-bypass hypoglycaemia: A review of current findings. DIABETES & METABOLISM 2011; 37:274-81. [DOI: 10.1016/j.diabet.2011.04.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 04/18/2011] [Accepted: 04/28/2011] [Indexed: 01/06/2023]
|
24
|
Middleton SJ, Balan K. Post-prandial reactive hypoglycaemia and diarrhea caused by idiopathic accelerated gastric emptying: a case report. J Med Case Rep 2011; 5:177. [PMID: 21569503 PMCID: PMC3113993 DOI: 10.1186/1752-1947-5-177] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2010] [Accepted: 05/13/2011] [Indexed: 01/03/2023] Open
Abstract
Introduction The majority of cases of post-prandial reactive hypoglycemia are considered idiopathic. Abnormalities of B-cell function and glucose regulation by insulin and glucagon have been postulated as causes but associated gastrointestinal dysfunction has not been reported. We report the first case of accelerated gastric emptying associated with post-prandial reactive hypoglycemia, abdominal bloating and diarrhea. We consider that gastric dysmotility is an important cause of this condition as treatment of the underlying abnormal gastric emptying allows effective control of symptoms. Case presentation A 20-year-old Caucasian woman presented with post-prandial fatigue, sweating, nausea, faintness and intermittent confusion, which had led to pre-syncope and syncope on occasions. She also experienced marked abdominal bloating and diarrhea over the same period. These episodes responded to oral administration of sweet drinks. Her symptoms were ameliorated by modification of her diet. Conclusion This is an original case report of the association of idiopathic accelerated gastric emptying with post-prandial reactive hypoglycemia and diarrhea. Family physicians, endocrinologists and gastroenterologists often consult patients with a constellation of post-prandial symptoms, which are considered to be idiopathic in most cases. This case indicates that gastric dysmotility might be the primary cause of these symptoms in some patients and, if found, offers a therapeutic target which in our case was successful.
Collapse
Affiliation(s)
- Stephen J Middleton
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Teaching Hospital NHS Trust, Hills Road, Cambridge, CB0 2QQ, UK.
| | | |
Collapse
|
25
|
Abstract
PURPOSE OF REVIEW To discuss the clinical scope and frequency of hypoglycemia following bariatric surgery, and possible mechanisms mediating this potentially life-threatening complication. RECENT FINDINGS Consequent to the rise in severe obesity, bariatric surgery is being performed with ever increasing frequency. Although data continue to accumulate supporting the myriad metabolic and other health benefits of bariatric surgery, there are also concerns regarding the mounting reports of severe hypoglycemia. The problem is particularly significant following gastric bypass, with the first concerns raised in 2005 following a case series reported from the Mayo Clinic. A Swedish nationwide cohort study recently estimated the frequency of this complication suggesting it was less than 1%. Hypotheses regarding the mechanism(s) by which hypoglycemia arise following gastric bypass range from beta cell expansion to altered beta cell function as well as nonbeta cell factors. SUMMARY Regardless of the incidence, the severity of hypoglycemia for select patients following gastric bypass necessitates that we strive to gain a better understanding of the underlying mechanisms. With such knowledge, those patients at greater risk for this complication might be identified preoperatively, and decisions regarding their surgical management optimized to reduce this risk.
Collapse
Affiliation(s)
- Karen E Foster-Schubert
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, V.A. Puget Sound Healthcare System, Seattle, Washington 98108, USA.
| |
Collapse
|
26
|
Bibliography. Current world literature. Adrenal cortex. Curr Opin Endocrinol Diabetes Obes 2011; 18:231-3. [PMID: 21522003 DOI: 10.1097/med.0b013e3283457c7d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
27
|
Halperin F, Patti ME, Skow M, Bajwa M, Goldfine AB. Continuous glucose monitoring for evaluation of glycemic excursions after gastric bypass. J Obes 2011; 2011:869536. [PMID: 21331295 PMCID: PMC3038694 DOI: 10.1155/2011/869536] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Accepted: 01/13/2011] [Indexed: 01/06/2023] Open
Abstract
Background. Hyperinsulinemic hypoglycemia with neuroglycopenia is a rare complication of Roux-en-Y gastric bypass (RYGB). We hypothesized that continuous glucose monitoring (CGM) would be useful to characterize glycemic variability after RYGB. Methods. CGM and mixed meal tolerance testing (MMTT) were performed on sixteen post-RYGB subjects, ten with a history of neuroglycopenia on medical treatment and six asymptomatic controls. Results. 9 of 10 subjects with neuroglycopenia developed hypoglycemia defined by glucose <70 mg/dL on CGM, and 3 of 9 on MMTT. In asymptomatic subjects, 3 of 6 had asymptomatic hypoglycemia during CGM, and 3 of 5 on MMTT. Therefore, the sensitivity and specificity to detect clinically significant hypoglycemia was 90% and 50% for CGM and 33% and 40% for MMTT. Conclusions. Asymptomatic hypoglycemia after RYGB is more frequent than commonly recognized. For clinicians evaluating patients for postbypass neuroglycopenia, CGM may be a valuable diagnostic tool.
Collapse
Affiliation(s)
- Florencia Halperin
- Brigham and Women's Hospital, Boston 02115, MA, USA
- Joslin Diabetes Center, Boston, MA 02215, USA
- Harvard Medical School, Boston 02115, MA, USA
| | - Mary Elizabeth Patti
- Joslin Diabetes Center, Boston, MA 02215, USA
- Harvard Medical School, Boston 02115, MA, USA
| | - Megan Skow
- Joslin Diabetes Center, Boston, MA 02215, USA
| | | | - Allison B. Goldfine
- Brigham and Women's Hospital, Boston 02115, MA, USA
- Joslin Diabetes Center, Boston, MA 02215, USA
- Harvard Medical School, Boston 02115, MA, USA
- *Allison B. Goldfine:
| |
Collapse
|