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Larsen AR, Brusgaard K, Christesen HT, Detlefsen S. Genotype-histotype-phenotype correlations in hyperinsulinemic hypoglycemia. Histol Histopathol 2024; 39:817-844. [PMID: 38305063 DOI: 10.14670/hh-18-709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Hyperinsulinemic hypoglycemia (HH) of pancreatic origin includes congenital hyperinsulinism (CHI), insulinoma, insulinomatosis, and adult-onset non-insulinoma persistent hyperinsulinemic hypoglycemia syndrome (NI-PHHS). In this review, we describe the genotype-histotype-phenotype correlations in HH and their therapeutic implications. CHI can occur from birth or later on in life. Histologically, diffuse CHI shows diffuse beta cell hypertrophy with a few giant nuclei per islet of Langerhans, most frequently caused by loss-of-function mutations in ABCC8 or KCNJ11. Focal CHI is histologically characterized by focal adenomatous hyperplasia consisting of confluent hyperplastic islets, caused by a paternal ABCC8/KCNJ11 mutation combined with paternal uniparental disomy of 11p15. CHI in Beckwith-Wiedemann syndrome is caused by mosaic changes in the imprinting region 11p15.4-11p15.5, leading to segmental or diffuse overgrowth of endocrine tissue in the pancreas. Morphological mosaicism of pancreatic islets is characterized by occurence of hyperplastic (type 1) islets in one or a few lobules and small (type 2) islets in the entire pancreas. Other rare genetic causes of CHI show less characteristic or unspecific histology. HH with a predominant adult onset includes insulinomas, which are pancreatic insulin-producing endocrine neoplasms, in some cases with metastatic potential. Insulinomas occur sporadically or as part of multiple endocrine neoplasia type 1 due to MEN1 mutations. MAFA mutations may histologically lead to insulinomatosis with insulin-producing neuroendocrine microadenomas or neuroendocrine neoplasms. NI-PHHS is mainly seen in adults and shows slight histological changes in some patients, which have been defined as major and minor criteria. The genetic cause is unknown in most cases. The diagnosis of HH, as defined by genetic, histological, and phenotypic features, has important implications for patient management and outcome.
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Affiliation(s)
- Annette Rønholt Larsen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
- Steno Diabetes Center, Odense University Hospital, Odense, Denmark
| | - Klaus Brusgaard
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
- Steno Diabetes Center, Odense University Hospital, Odense, Denmark
| | - Henrik Thybo Christesen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
- Steno Diabetes Center, Odense University Hospital, Odense, Denmark
| | - Sönke Detlefsen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark.
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2
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Hazlehurst J, Khoo B, Lobato CB, Ilesanmi I, Abbott S, Chan T, Pillai S, Maslin K, Purkayastha S, McGowan B, Andrews R, Nicholson E, McCullough K, Albon L, Batterham R, Dimitriadis GK, Forbes S, Bewick G, Tan TMM. Society for Endocrinology guidelines for the diagnosis and management of post-bariatric hypoglycaemia. Endocr Connect 2024; 13:EC-23-0285. [PMID: 38451861 PMCID: PMC11046333 DOI: 10.1530/ec-23-0285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 03/07/2024] [Indexed: 03/09/2024]
Abstract
Post bariatric hypoglycaemia (PBH) is typically a post-prandial hypoglycaemia occurring about 2-4 hours after eating in people who have undergone bariatric surgery. PBH develops relatively late after surgery and often after discharge from post-surgical follow-up by bariatric teams, leading to variability in diagnosis and management in non-specialist centres. AIM to improve and standardise clinical practice in the diagnosis and management of PBH. OBJECTIVES (1) to undertake an up-to-date review of the current literature; (2) to formulate practical and evidence-based guidance with regards on the diagnosis and treatment of PBH; (3) to recommend future avenues for research in this condition. METHOD A scoping review was undertaken after an extensive literature search. A consensus on the guidance and confidence in the recommendations was reached by the steering group authors prior to review by key stakeholders. OUTCOME We make pragmatic recommendations for the practical diagnosis and management of PBH including criteria for diagnosis and recognition, as well as recommendations for research areas that should be explored.
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Affiliation(s)
- Jonathan Hazlehurst
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Bernard Khoo
- Endocrinology, Division of Medicine, University College London, London, UK
| | - Carolina Brito Lobato
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Medicine, Copenhagen University Hospital – Amager and Hvidovre, Hvidovre, Denmark
| | - Ibiyemi Ilesanmi
- Section of Endocrinology and Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
| | - Sally Abbott
- Department of Dietetics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Tin Chan
- Faculty of Medicine, Chinese University of Hong Kong, Hong Kong
| | - Sanesh Pillai
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Kate Maslin
- School of Nursing and Midwifery, University of Plymouth, Plymouth, UK
| | - Sanjay Purkayastha
- Brunel University, London, UK
- Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, UK
| | - Barbara McGowan
- Endocrinology, Guys’ and St Thomas’s NHS Foundation Trust, London, UK
| | - Rob Andrews
- University of Exeter Medical School, Exeter, UK
| | | | | | - Lorraine Albon
- University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - Rachel Batterham
- Endocrinology, Division of Medicine, University College London, London, UK
| | | | - Shareen Forbes
- BHF Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Gavin Bewick
- School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Tricia M-M Tan
- Section of Endocrinology and Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
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3
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Masclee GMC, Masclee AAM. Dumping Syndrome: Pragmatic Treatment Options and Experimental Approaches for Improving Clinical Outcomes. Clin Exp Gastroenterol 2023; 16:197-211. [PMID: 37954129 PMCID: PMC10637186 DOI: 10.2147/ceg.s392265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/22/2023] [Indexed: 11/14/2023] Open
Abstract
Dumping syndrome is a common complication after esophageal, gastric and bariatric surgery and has a significant negative impact on the quality of life of patients. This narrative review describes the clinical syndrome, pathophysiology, diagnosis and reports on standard and pragmatic therapeutical treatment options in order to improve the clinical outcome of patients with dumping syndrome. Dumping syndrome consists of early and late dumping symptoms and can be diagnosed using clinical parameters with the help of the Sigstad's score, questionnaires or by provocative testing. The prevalence of dumping syndrome varies depending on the employed definition of dumping syndrome. Overall, dumping syndrome is more frequent nowadays due to increasing numbers of upper gastrointestinal and bariatric surgeries being performed. First treatment step includes dietary adjustment and dietary supplements, which are often sufficient to manage symptoms for the majority of patients. Next step of therapy includes acarbose, which is effective for late dumping symptoms, but the use is limited due to side effects. Somatostatin analogues are indicated after these two steps have failed. Somatostatin analogues are very effective for controlling early and late dumping, also in the long term. Glucagon like peptide-1 receptor agonists, endoscopic and surgical (re)interventions are reported as treatment options for refractory dumping syndrome; however, their use is not recommended in clinical practice due to the limited evidence on and uncertainty of outcomes. These alternatives should be considered only as last resort options in patients with otherwise refractory and invalidating dumping syndrome.
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Affiliation(s)
- Gwen M C Masclee
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Ad A M Masclee
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center +, Maastricht, the Netherlands
- NUTRIM, School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
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4
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Parzer V, Resl M, Stechemesser L, Wakolbinger M, Itariu B, Brix JM. [Postoperative management]. Wien Klin Wochenschr 2023; 135:729-742. [PMID: 37821696 PMCID: PMC10567962 DOI: 10.1007/s00508-023-02272-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2023] [Indexed: 10/13/2023]
Abstract
Bariatric surgery results in significant weight loss, reduction or even remission of obesity-associated comorbidities, reduced mortality, and improved quality of life in many patients; however, obesity is a chronic disease, thus follow-up care is required after bariatric surgery. Furthermore, specific issues, such as micronutrient deficiencies and subsequent complications, can arise both in the short-term and the long-term. Abdominal pain after bariatric surgery must always be regarded as a serious symptom. A further focus should be on the diagnosis and treatment of dumping syndrome. Patients with type 2 diabetes should be regularly screened for recurrent hyperglycemia as well as specific sequelae, even though blood glucose levels may be substantially improved or normalized. In addition to centers with multidisciplinary teams, primary care and, in particular, general practitioners will play an increasingly more important role in the follow-up care after bariatric surgery.
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Affiliation(s)
- Verena Parzer
- 1. Medizinische Abteilung mit Diabetologie, Endokrinologie und Nephrologie, Klinik Landstraße, Wien, Österreich
- Karl Landsteiner Institut für Adipositas und Stoffwechselerkrankungen, Klinik Landstraße, Wien, Österreich
| | - Michael Resl
- ICMR - Institute for Cardiovascular and Metabolic Research, Johannes Kepler Universität Linz, Linz, Österreich
- Abteilung für Innere Medizin mit Diabetologie, Gastroenterologie und Hepatologie, Rheumatologie und Intensivmedizin, Konventhospital der Barmherzigen Brüder Linz, Linz, Österreich
| | - Lars Stechemesser
- Universitätsklinik für Innere Medizin I mit Gastroenterologie, Hepatologie, Nephrologie, Stoffwechsel und Diabetologie, Uniklinikum der Paracelsus Medizinischen Privatuniversität, Salzburg, Österreich
| | - Maria Wakolbinger
- Abteilung für Sozial- und Präventivmedizin, Zentrum für Public Health, Medizinische Universität Wien, Wien, Österreich
| | - Bianca Itariu
- Klinische Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich.
| | - Johanna Maria Brix
- 1. Medizinische Abteilung mit Diabetologie, Endokrinologie und Nephrologie, Klinik Landstraße, Wien, Österreich
- Karl Landsteiner Institut für Adipositas und Stoffwechselerkrankungen, Klinik Landstraße, Wien, Österreich
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5
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Alkhaled L, Al-Kurd A, Butsch WS, Kashyap SR, Aminian A. Diagnosis and management of post-bariatric surgery hypoglycemia. Expert Rev Endocrinol Metab 2023; 18:459-468. [PMID: 37850227 DOI: 10.1080/17446651.2023.2267136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 10/02/2023] [Indexed: 10/19/2023]
Abstract
INTRODUCTION While bariatric surgery remains the most effective treatment for obesity that allows substantial weight loss with improvement and possibly remission of obesity-associated comorbidities, some postoperative complications may occur. Managing physicians need to be familiar with the common problems to ensure timely and effective management. Of these complications, postoperative hypoglycemia is an increasingly recognized complication of bariatric surgery that remains underreported and underdiagnosed. AREA COVERED This article highlights the importance of identifying hypoglycemia in patients with a history of bariatric surgery, reviews pathophysiology and addresses available nutritional, pharmacological and surgical management options. Systemic evaluation including careful history taking, confirmation of hypoglycemia and biochemical assessment is essential to establish accurate diagnosis. Understanding the weight-dependent and weight-independent mechanisms of improved postoperative glycemic control can provide better insight into the causes of the exaggerated responses that lead to postoperative hypoglycemia. EXPERT OPINION Management of post-operative hypoglycemia can be challenging and requires a multidisciplinary approach. While dietary modification is the mainstay of treatment for most patients, some patients may benefit from pharmacotherapy (e.g. GLP-1 receptor antagonist); Surgery (e.g. reversal of gastric bypass) is reserved for unresponsive severe cases. Additional research is needed to understand the underlying pathophysiology with a primary aim in optimizing diagnostics and treatment options.
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Affiliation(s)
- Lina Alkhaled
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH USA
- Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, OH USA
| | - Abbas Al-Kurd
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH USA
- Department of General Surgery, Henry Ford Hospital, Detroit, MI USA
| | - W Scott Butsch
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH USA
| | - Sangeeta R Kashyap
- Division of Endocrinology, Diabetes and Metabolism, Weill Cornell Medicine, New York, NY USA
| | - Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH USA
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Dieterle MP, Husari A, Prozmann SN, Wiethoff H, Stenzinger A, Röhrich M, Pfeiffer U, Kießling WR, Engel H, Sourij H, Steinberg T, Tomakidi P, Kopf S, Szendroedi J. Diffuse, Adult-Onset Nesidioblastosis/Non-Insulinoma Pancreatogenous Hypoglycemia Syndrome (NIPHS): Review of the Literature of a Rare Cause of Hyperinsulinemic Hypoglycemia. Biomedicines 2023; 11:1732. [PMID: 37371827 DOI: 10.3390/biomedicines11061732] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Differential diagnosis of hypoglycemia in the non-diabetic adult patient is complex and comprises various diseases, including endogenous hyperinsulinism caused by functional β-cell disorders. The latter is also designated as nesidioblastosis or non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS). Clinically, this rare disease presents with unspecific adrenergic and neuroglycopenic symptoms and is, therefore, often overlooked. A combination of careful clinical assessment, oral glucose tolerance testing, 72 h fasting, sectional and functional imaging, and invasive insulin measurements can lead to the correct diagnosis. Due to a lack of a pathophysiological understanding of the condition, conservative treatment options are limited and mostly ineffective. Therefore, nearly all patients currently undergo surgical resection of parts or the entire pancreas. Consequently, apart from faster diagnosis, more elaborate and less invasive treatment options are needed to relieve the patients from the dangerous and devastating symptoms. Based on a case of a 23-year-old man presenting with this disease in our department, we performed an extensive review of the medical literature dealing with this condition and herein presented a comprehensive discussion of this interesting disease, including all aspects from epidemiology to therapy.
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Affiliation(s)
- Martin Philipp Dieterle
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Ayman Husari
- Department of Orthodontics, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Sophie Nicole Prozmann
- Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Hendrik Wiethoff
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Albrecht Stenzinger
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Manuel Röhrich
- Department of Nuclear Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Uwe Pfeiffer
- Pfalzklinikum for Psychiatry and Neurology AdÖR, Weinstr. 100, 76889 Klingenmünster, Germany
| | | | - Helena Engel
- Cancer Immune Regulation Group, German Cancer Research Center, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Harald Sourij
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8010 Graz, Austria
- Interdisciplinary Metabolic Medicine Trials Unit, Medical University of Graz, 8010 Graz, Austria
| | - Thorsten Steinberg
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Pascal Tomakidi
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Stefan Kopf
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
| | - Julia Szendroedi
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
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7
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de Heide LJM, Wouda SHT, Peters VJT, Oosterwerff-Suiker M, Gerdes VA, Emous M, van Beek AP. Medical and surgical treatment of postbariatric hypoglycaemia: Retrospective data from daily practice. Diabetes Obes Metab 2023; 25:735-747. [PMID: 36377811 DOI: 10.1111/dom.14920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022]
Abstract
AIM To evaluate medical and surgical treatment of postbariatric hypoglycaemia (PBH) in daily practice. MATERIALS AND METHODS Retrospective data were extracted from medical records from four hospitals. PBH was defined by neuroglycopenic symptoms together with a documented glucose <3.0 mmol/L in the postprandial setting after previous bariatric surgery. Data were scored semiquantitatively on efficacy and side effects by two reviewers independently. Duration of efficacy and of use were calculated. RESULTS In total, 120 patients were included with a median follow-up of 27 months with a mean baseline age of 41 years, total weight loss of 33% and glucose nadir 2.3 mmol/L. Pharmacotherapy consisted of acarbose, diazoxide, short- and long-acting octreotide and glucagon-like peptide-1 receptor agonist analogues (liraglutide and semaglutide) with an overall efficacy in 45%-75% of patients. Combination therapy with two drugs was used by 30 (25%) patients. The addition of a second drug was successful in over half of the patients. Long-acting octreotide and the glucagon-like peptide-1 receptor agonist analogues scored best in terms of efficacy and side effects with a median duration of use of 35 months for octreotide. Finally, 23 (19%) patients were referred for surgical intervention. Efficacy of the surgical procedures, pouch banding, G-tube placement in remnant stomach and Roux-en-Y gastric bypass reversal, pooled together, was 79% with a median duration of initial effect of 13 months. CONCLUSIONS In daily practice, pharmacotherapy for PBH was successful in half to three quarters of patients. Combination therapy was often of value. One in five patients finally needed a surgical procedure, with overall good results.
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Affiliation(s)
- Loek J M de Heide
- Centre for Obesity Northern Netherlands, Department of Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Sterre H T Wouda
- Department of Biomedical Science, University of Groningen, Groningen, The Netherlands
| | - Vincent J T Peters
- Department of Internal Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
- Department of Management, Tilburg University, Tilburg, The Netherlands
| | | | - Victor A Gerdes
- Department of Internal Medicine, Spaarne Hospital, Hoofddorp, The Netherlands
| | - Marloes Emous
- Centre for Obesity Northern Netherlands, Department of Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - André P van Beek
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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8
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Sandoval DA, Patti ME. Glucose metabolism after bariatric surgery: implications for T2DM remission and hypoglycaemia. Nat Rev Endocrinol 2023; 19:164-176. [PMID: 36289368 PMCID: PMC10805109 DOI: 10.1038/s41574-022-00757-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2022] [Indexed: 11/09/2022]
Abstract
Although promising therapeutics are in the pipeline, bariatric surgery (also known as metabolic surgery) remains our most effective strategy for the treatment of obesity and type 2 diabetes mellitus (T2DM). Of the many available options, Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) are currently the most widely used procedures. RYGB and VSG have very different anatomical restructuring but both surgeries are effective, to varying degrees, at inducing weight loss and T2DM remission. Both weight loss-dependent and weight loss-independent alterations in multiple tissues (such as the intestine, liver, pancreas, adipose tissue and skeletal muscle) yield net improvements in insulin resistance, insulin secretion and insulin-independent glucose metabolism. In a subset of patients, post-bariatric hypoglycaemia can develop months to years after surgery, potentially reflecting the extreme effects of potent glucose reduction after surgery. This Review addresses the effects of bariatric surgery on glucose regulation and the potential mechanisms responsible for both the resolution of T2DM and the induction of hypoglycaemia.
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Affiliation(s)
- Darleen A Sandoval
- Department of Paediatrics, Section of Nutrition, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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9
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BYPASS-OMA: Hypoglycemic Hyperinsulinemic Nesidioblastosis after Gastric Bypass Surgery-A Case Report and Review of the Literature. Case Rep Endocrinol 2022; 2022:5472304. [PMID: 36588628 PMCID: PMC9800099 DOI: 10.1155/2022/5472304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/18/2022] [Accepted: 11/08/2022] [Indexed: 12/24/2022] Open
Abstract
This rare case vignette describes hypoglycemic, hyperinsulinemic nesidioblastosis in a female patient with prior Roux-en-Y gastric bypass. The patient presented with severe symptomatic hypoglycemia resistant to IV dextrose and diazoxide, requiring surgical resection. Traditional imaging found nonspecific findings, and biochemical analysis was inconsistent with insulinoma. A gallium-68 dotatate PET scan was utilized to successfully localize the tumor in the distal pancreas. She underwent laparoscopic resection of the distal pancreatic lesion with resolution of her symptoms and return to euglycemia. The histological evaluation confirmed the diagnosis of nesidioblastosis. Nesidioblastosis is a rare complication of bariatric surgery that may be more clinically relevant with rising prevalence of obesity. Diagnosis with conventional imaging modalities may be challenging; however, the dotatate PET scan may have high utility in detecting lesions. It is essential for clinicians to consider nesidioblastosis in the differential diagnosis of hyperinsulinemic hypoglycemic conditions and recognize there may be a link with increasing rates of bariatric surgery.
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10
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Patience N, Sheehan A, Cummings C, Patti ME. Medical Nutrition Therapy and Other Approaches to Management of Post-bariatric Hypoglycemia: A Team-Based Approach. Curr Obes Rep 2022; 11:277-286. [PMID: 36074258 DOI: 10.1007/s13679-022-00482-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW This manuscript provides a review of post-bariatric hypoglycemia (PBH) with a special focus on the role of the registered dietitian-nutritionist (RDN) and medical nutrition therapy (MNT) recommendations as foundational for management. RECENT FINDINGS As the number of bariatric surgeries rises yearly, with 256,000 performed in 2019, PBH is an increasingly encountered late complication. Following Roux-en-Y (RYGB) or vertical sleeve gastrectomy (VSG), about 1/3 of patients report symptoms suggestive of at least mild postprandial hypoglycemia, with severe and/or medically confirmed hypoglycemia in 1-10%. Anatomical alterations, changes in GLP1 and other intestinally derived hormones, excessive insulin response, reduced insulin clearance, impaired counterregulatory hormone response to hypoglycemia, and other factors contribute to PBH. MNT is the cornerstone of multidisciplinary treatment, with utilization of personal continuous glucose monitoring to improve safety when possible. While many individuals require pharmacotherapy, there are no currently approved medications for PBH. Increasing awareness and identification of individuals at risk for or with PBH is critical given the potential impact on safety, nutrition, and quality of life. A team-based approach involving the individual, the RDN, and other clinicians is essential in providing ongoing assessment and individualization of MNT in the long-term management of PBH.
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Affiliation(s)
- Nicole Patience
- Clinic Division, Joslin Diabetes Center, Inc, One Joslin Place, Boston, MA, 02215, USA.
| | - Amanda Sheehan
- Clinic Division, Joslin Diabetes Center, Inc, One Joslin Place, Boston, MA, 02215, USA
- Research Division, Joslin Diabetes Center, Boston, MA, USA
| | | | - Mary Elizabeth Patti
- Clinic Division, Joslin Diabetes Center, Inc, One Joslin Place, Boston, MA, 02215, USA.
- Research Division, Joslin Diabetes Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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11
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Terryn FX, Majerus B. Combined laparoscopic Roux-en-Y gastric bypass reversal and gastric banding to treat severe hyperinsulinemic hypoglycemia: A case report and surgical video. Int J Surg Case Rep 2022; 96:107271. [PMID: 35716625 PMCID: PMC9213248 DOI: 10.1016/j.ijscr.2022.107271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/29/2022] [Accepted: 05/29/2022] [Indexed: 02/07/2023] Open
Abstract
Non insulinoma pancreatogenous hypoglycemia syndrome is a recently described complication of Roux-en-Y gastric bypass Currently, there is no Gold Standard treatment. In this case, we successfully performed a combined laparoscopic reversal of gastric bypass and gastric banding
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Affiliation(s)
- F.-X. Terryn
- Europe Hospitals – Sainte Elisabeth, Brussels, Belgium,Corresponding author.
| | - B. Majerus
- Clinique Saint Pierre, Ottignies, Belgium
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12
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Sheehan A, Goldfine A, Bajwa M, Wolfs D, Kozuka C, Piper J, Fowler K, Patti ME. Pramlintide for post-bariatric hypoglycaemia. Diabetes Obes Metab 2022; 24:1021-1028. [PMID: 35137513 PMCID: PMC9035096 DOI: 10.1111/dom.14665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/27/2022] [Accepted: 02/06/2022] [Indexed: 11/27/2022]
Abstract
AIMS The aim of this study was to examine the hypothesis that pramlintide would reduce hypoglycaemia by slowing gastric emptying and reducing postprandial glucagon secretion, thus limiting postprandial glycaemic excursions and insulin secretion, and thus to determine the efficacy of pramlintide on frequency and severity of hypoglycaemia in post-bariatric hypoglycaemia (PBH). MATERIALS AND METHODS Participants with PBH following gastric bypass were recruited from outpatient clinics at the Joslin Diabetes Center, Boston, Massachusetts for an open-label study of pramlintide efficacy over 8 weeks. Twenty-three participants were assessed for eligibility, 20 participants had at least one pramlintide dose, and 14 completed the study. A mixed-meal tolerance test (MMTT) was performed at baseline and after 8 weeks of subcutaneous pramlintide with a sequential dose increase to a maximum of 120 micrograms (mean 69 ± 32 mcg) three times daily. The primary endpoint was change in glucose excursions during the MMTT. Secondary measures included MMTT insulin response, satiety and dumping score, percentage time with sensor glucose (SG) <3.9 mM, and number of days with minimum SG <3 mM, during masked continuous glucose monitoring. RESULTS There were no differences in MMTT glucose, glucagon or insulin between baseline and post treatment. We observed no significant change in satiety or dumping scores. The overall frequency of low SG values did not change, although there was substantial inter-individual variability. CONCLUSIONS In PBH, pramlintide does not modulate glycaemic or insulin responses, satiety, or dumping scores during an MMTT and does not impact glycaemic excursions or decrease low SG levels in the outpatient setting.
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Affiliation(s)
- Amanda Sheehan
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Allison Goldfine
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Muhammed Bajwa
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Danielle Wolfs
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Chisayo Kozuka
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jacqueline Piper
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Kristen Fowler
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Mary Elizabeth Patti
- Research Division, Joslin Diabetes Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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13
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Hypoglycemia and Dysautonomia After Bariatric Surgery: a Systematic Review and Perspective. Obes Surg 2022; 32:1681-1688. [PMID: 35133603 DOI: 10.1007/s11695-022-05960-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/24/2022] [Accepted: 02/02/2022] [Indexed: 12/27/2022]
Abstract
INTRODUCTION With the increasing performance of bariatric surgery, rare complications are becoming prevalent. We review the diagnosis and treatment of dysautonomia after bariatric surgery and the limited treatment options available. We summarize the suggested mechanisms and explain why a complete understanding of the etiology has yet to be determined. METHODS In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review was performed. RESULTS Of 448 studies identified in the literature search, 4 studies were reviewed, describing 87 patients diagnosed with dysautonomia. We present a patient who developed severe dysautonomia following conversion of sleeve gastrectomy to gastric bypass. CONCLUSION Treatment needs to focus on optimizing nutrition, avoiding hypoglycemia, and optimizing volume status.
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Craig CM, Lawler HM, Lee CJE, Tan M, Davis DB, Tong J, Glodowski M, Rogowitz E, Karaman R, McLaughlin TL, Porter L. PREVENT: A Randomized, Placebo-controlled Crossover Trial of Avexitide for Treatment of Postbariatric Hypoglycemia. J Clin Endocrinol Metab 2021; 106:e3235-e3248. [PMID: 33616643 PMCID: PMC8277203 DOI: 10.1210/clinem/dgab103] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Indexed: 02/06/2023]
Abstract
CONTEXT Postbariatric hypoglycemia (PBH), characterized by enteroinsular axis overstimulation and hyperinsulinemic hypoglycemia, is a complication of bariatric surgery for which there is no approved therapy. OBJECTIVE To evaluate efficacy and safety of avexitide [exendin (9-39)], a glucagon-like peptide-1 antagonist, for treatment of PBH. METHODS A multicenter, Phase 2, randomized, placebo-controlled crossover study (PREVENT). Eighteen female patients with PBH were given placebo for 14 days followed by avexitide 30 mg twice daily and 60 mg once daily, each for 14 days in random order. The main outcome measures were glucose nadir and insulin peak during mixed-meal tolerance testing (MMTT) and hypoglycemic events captured by self-monitoring of blood glucose (SMBG), electronic diary, and blinded continuous glucose monitoring (CGM). RESULTS Compared with placebo, avexitide 30 mg twice daily and 60 mg once daily raised the glucose nadir by 21% (P = .001) and 26% (P = .0002) and lowered the insulin peak by 23% (P = .029) and 21% (P = .042), corresponding to 50% and 75% fewer participants requiring rescue during MMTT, respectively. Significant reductions in rates of Levels 1 to 3 hypoglycemia were observed, defined, respectively, as SMBG <70 mg/dL, SMBG <54 mg/dL, and a severe event characterized by altered mental and/or physical function requiring assistance. CGM demonstrated reductions in hypoglycemia without induction of clinically relevant hyperglycemia. Avexitide was well tolerated, with no increase in adverse events. CONCLUSION Avexitide administered for 28 days was well tolerated and resulted in robust and consistent improvements across multiple clinical and metabolic parameters, reinforcing the targeted therapeutic approach and demonstrating durability of effect. Avexitide may represent a first promising treatment for patients with severe PBH.
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Affiliation(s)
- Colleen M Craig
- Eiger BioPharmaceuticals, Inc., Palo Alto, CA 94306, USA
- Correspondence: Colleen M Craig, MD, 2155 Park Boulevard, Palo Alto, CA, USA 94306.
| | - Helen Margaret Lawler
- Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Clare Jung Eun Lee
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Marilyn Tan
- Division of Endocrinology, Gerontology, and Metabolism, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Dawn Belt Davis
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Wisconsin, Madison, WI 53705, USA
| | - Jenny Tong
- Division of Endocrinology, Metabolism, and Nutrition, Department of Medicine, Duke University School of Medicine, Durham, NC 27710, USA
| | - Michele Glodowski
- Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Elisa Rogowitz
- Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Rowan Karaman
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Wisconsin, Madison, WI 53705, USA
| | | | - Lisa Porter
- Eiger BioPharmaceuticals, Inc., Palo Alto, CA 94306, USA
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15
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Surgical Treatment for Postprandial Hypoglycemia After Roux-en-Y Gastric Bypass: a Literature Review. Obes Surg 2021; 31:1801-1809. [PMID: 33523415 DOI: 10.1007/s11695-021-05251-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 01/15/2021] [Accepted: 01/20/2021] [Indexed: 10/22/2022]
Abstract
Roux-en-Y gastric bypass (RYGB) is an effective treatment for severe obesity and obesity-related comorbidities. Postprandial hypoglycemia may occur as a long-term complication after RYGB. This study reviews the literature on surgical treatment for intractable post-RYGB hypoglycemia to provide updated information. A search was performed in Embase and PubMed, and 25 papers were identified. Thirteen papers on reversal were included. Resolution of postprandial hypoglycemic symptoms occurred in 42/48 (88%) patients after reversal. Twelve papers on pancreatectomy were included. Resolution occurred in 27/50 (54%) patients after pancreatectomy. The optimal surgical treatment for intractable post-RYGB hypoglycemia has not been defined, but reversal of RYGB seems to be more effective than other treatments. Further research on etiology and long-term evaluation of surgical outcomes may refine treatment options.
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16
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Zhou LY, Deng MQ, Xiao XH. Potential contribution of the gut microbiota to hypoglycemia after gastric bypass surgery. Chin Med J (Engl) 2020; 133:1834-1843. [PMID: 32649508 PMCID: PMC7470015 DOI: 10.1097/cm9.0000000000000932] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Indexed: 12/12/2022] Open
Abstract
Obesity has become a global health problem. Lifestyle modification and medical treatment only appear to yield short-term weight loss. Roux-en-Y gastric bypass (RYGB) is the most popular bariatric procedure, and it sustains weight reduction and results in the remission of obesity-associated comorbidities for obese individuals. However, patients who undergo this surgery may develop hypoglycemia. To date, the diagnosis is challenging and the prevalence of post-RYGB hypoglycemia (PRH) is unclear. RYGB alters the anatomy of the upper gastrointestinal tract and has a combined effect of caloric intake restriction and nutrient malabsorption. Nevertheless, the physiologic changes after RYGB are complex. Although hyperinsulinemia, incretin effects, dysfunction of β-cells and α-cells, and some other factors have been widely investigated and are reported to be possible mediators of PRH, the pathogenesis is still not completely understood. In light of the important role of the gut microbiome in metabolism, we hypothesized that the gut microbiome might also be a critical link between RYGB and hypoglycemia. In this review, we mainly highlight the current possible factors predisposing individuals to PRH, particularly related to the gut microbiota, which may yield significant insights into the intestinal regulation of glucose metabolic homeostasis and provide novel clues to improve the treatment of type 2 diabetes mellitus.
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Affiliation(s)
- Li-Yuan Zhou
- Key Laboratory of Endocrinology, Translational Medicine Center, Ministry of Health, Department of Endocrinology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
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17
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Scarpellini E, Arts J, Karamanolis G, Laurenius A, Siquini W, Suzuki H, Ukleja A, Van Beek A, Vanuytsel T, Bor S, Ceppa E, Di Lorenzo C, Emous M, Hammer H, Hellström P, Laville M, Lundell L, Masclee A, Ritz P, Tack J. International consensus on the diagnosis and management of dumping syndrome. Nat Rev Endocrinol 2020; 16:448-466. [PMID: 32457534 PMCID: PMC7351708 DOI: 10.1038/s41574-020-0357-5] [Citation(s) in RCA: 105] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/31/2020] [Indexed: 12/14/2022]
Abstract
Dumping syndrome is a common but underdiagnosed complication of gastric and oesophageal surgery. We initiated a Delphi consensus process with international multidisciplinary experts. We defined the scope, proposed statements and searched electronic databases to survey the literature. Eighteen experts participated in the literature summary and voting process evaluating 62 statements. We evaluated the quality of evidence using grading of recommendations assessment, development and evaluation (GRADE) criteria. Consensus (defined as >80% agreement) was reached for 33 of 62 statements, including the definition and symptom profile of dumping syndrome and its effect on quality of life. The panel agreed on the pathophysiological relevance of rapid passage of nutrients to the small bowel, on the role of decreased gastric volume capacity and release of glucagon-like peptide 1. Symptom recognition is crucial, and the modified oral glucose tolerance test, but not gastric emptying testing, is useful for diagnosis. An increase in haematocrit >3% or in pulse rate >10 bpm 30 min after the start of the glucose intake are diagnostic of early dumping syndrome, and a nadir hypoglycaemia level <50 mg/dl is diagnostic of late dumping syndrome. Dietary adjustment is the agreed first treatment step; acarbose is effective for late dumping syndrome symptoms and somatostatin analogues are preferred for patients who do not respond to diet adjustments and acarbose.
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Affiliation(s)
- Emidio Scarpellini
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing (ChroMetA), Catholic University of Leuven, Leuven, Belgium
| | - Joris Arts
- Gastroenterology Division, St Lucas Hospital, Bruges, Belgium
| | - George Karamanolis
- 2nd Department of Internal Medicine - Propaedeutic, Hepatogastroenterology Unit, Attikon University Hospital, Medical School, Athens University, Athens, Greece
| | - Anna Laurenius
- Department of Gastrosurgical Research and Education, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Walter Siquini
- Politechnic University of Marche, "Madonna del Soccorso" General Hospital, San Benedetto del Tronto, Italy
| | - Hidekazu Suzuki
- Department of Gastroenterology and Hepatology, Tokai University School of Medicine, Isehara, Japan
| | - Andrew Ukleja
- Division of Gastroenterology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Andre Van Beek
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Tim Vanuytsel
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing (ChroMetA), Catholic University of Leuven, Leuven, Belgium
| | - Serhat Bor
- Division of Gastroenterology, Ege University School of Medicine, Izmir, Turkey
| | - Eugene Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Carlo Di Lorenzo
- Division of Pediatric Gastroenterology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Marloes Emous
- Department of Bariatric and Metabolic Surgery, Medical Center Leeuwarden, Leeuwarden, Netherlands
| | - Heinz Hammer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Per Hellström
- Department of Medical Sciences, Gastroenterology/Hepatology, Uppsala University, Uppsala, Sweden
| | - Martine Laville
- Department of Endocrinology, Claude Bernard University, Lyon, France
| | - Lars Lundell
- Department of Surgery Hospital, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Ad Masclee
- Department of Gastroenterology-Hepatology, University Hospital Leiden, Leiden, Netherlands
| | | | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism and Ageing (ChroMetA), Catholic University of Leuven, Leuven, Belgium.
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18
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Vargas EJ, Abu Dayyeh BK, Storm AC, Bazerbachi F, Matar R, Vella A, Kellogg T, Stier C. Endoscopic management of dumping syndrome after Roux-en-Y gastric bypass: a large international series and proposed management strategy. Gastrointest Endosc 2020; 92:91-96. [PMID: 32112780 DOI: 10.1016/j.gie.2020.02.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 02/17/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Roux-en-Y gastric bypass (RYGB) is refractory to lifestyle and pharmacotherapy measures, requiring reversal of the patient's bariatric surgery. Reversal can lead to weight regain and recrudescence of their comorbidities. Our aim was to report a multicenter experience on the endoscopic management of refractory dumping syndrome with endoscopic transoral outlet reduction (TORe). METHODS A multicenter international series of consecutive patients who underwent TORe with a full-thickness endoscopic suturing device was analyzed for technical success, improvement in Sigstad scores, and weight trajectories after the procedure. Failure was defined as needing an enteral feeding tube, surgical reversal, or repeat TORe. RESULTS One hundred fifteen patients across 2 large academic centers in Germany and the United States underwent TORe for dumping syndrome. Patient age was mean 8.9 ± 1.1 years from their initial RYGB with an average percent total body weight loss of 31% ± 10.6% at the time of endoscopy. Three months postprocedure, the Sigstad score improved from a mean of 17 ± 6.1 to 2.6 ± 1.9 (paired t test P = .0001) with only 2% of patients (n = 2) experiencing weight gain. Mean weight loss and percentage of total body weight loss 3 months post-TORe were 9.47 ± 3.6 kg and 9.47% ± 2.5%, respectively. Six patients (5%) failed initial endoscopic therapy, with 50% (n = 3) successfully treated with a repeat TORe. Three patients underwent surgical reversal, indicating an overall 97% endoscopic success rate. CONCLUSIONS TORe as an adjunct to lifestyle and pharmacologic therapy for refractory dumping syndrome is safe and effective at improving dumping syndrome and reducing rates of surgical revision.
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Affiliation(s)
- Eric J Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Fateh Bazerbachi
- Division of Gastroenterology, Interventional Endoscopy Program, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Reem Matar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Adrian Vella
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Todd Kellogg
- Department of General Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Christine Stier
- Department of Endocrinology, University Hospital, Würzburg, Germany
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19
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Abstract
As the prevalence of obesity has increased, bariatric surgery has become more common because of its proven efficacy at promoting weight loss and improving weight-related medical comorbidities. Although generally successful, bariatric surgery may also lead to complications and negatively affect health. This article highlights some common and rare complications of bariatric surgery. Specifically, it discusses the risk of nutrient deficiencies (which is influenced by surgery type) and their downstream effects, including ill-effects on bone health. Rarer complications, such as postbypass hypoglycemia and alcohol use disorder, are also discussed.
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Affiliation(s)
- Maria L Collazo-Clavell
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Meera Shah
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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20
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Mulla CM, Zavitsanou S, Laguna Sanz AJ, Pober D, Richardson L, Walcott P, Arora I, Newswanger B, Cummins MJ, Prestrelski SJ, Doyle FJ, Dassau E, Patti ME. A Randomized, Placebo-Controlled Double-Blind Trial of a Closed-Loop Glucagon System for Postbariatric Hypoglycemia. J Clin Endocrinol Metab 2020; 105:5623031. [PMID: 31714583 PMCID: PMC7174034 DOI: 10.1210/clinem/dgz197] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 11/08/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postbariatric hypoglycemia (PBH) can threaten safety and reduce quality of life. Current therapies are incompletely effective. METHODS Patients with PBH were enrolled in a double-blind, placebo-controlled, crossover trial to evaluate a closed-loop glucose-responsive automated glucagon delivery system designed to reduce severe hypoglycemia. A hypoglycemia detection and mitigation algorithm was embedded in the artificial pancreas system connected to a continuous glucose monitor (CGM, Dexcom) driving a patch infusion pump (Insulet) filled with liquid investigational glucagon (Xeris) or placebo (vehicle). Sensor/plasma glucose responses to mixed meal were assessed during 2 study visits. The system delivered up to 2 doses of study drug (300/150 μg glucagon or equal-volume vehicle) if triggered by the algorithm. Rescue dextrose was given for plasma glucose <55 mg/dL or neuroglycopenia. RESULTS Twelve participants (11 females/1 male, age 52 ± 2, 8 ± 1 years postsurgery, mean ± SEM) completed all visits. Predictive hypoglycemia alerts prompted automated drug delivery postmeal, when sensor glucose was 114 ± 7 vs 121 ± 5 mg/dL (P = .39). Seven participants required rescue glucose after vehicle but not glucagon (P = .008). Five participants had severe hypoglycemia (<55 mg/dL) after vehicle but not glucagon (P = .03). Nadir plasma glucose was higher with glucagon vs vehicle (67 ± 3 vs 59 ± 2 mg/dL, P = .004). Plasma glucagon rose after glucagon delivery (1231 ± 187 vs 16 ± 1 pg/mL at 30 minutes, P = .001). No rebound hyperglycemia occurred. Transient infusion site discomfort was reported with both glucagon (n = 11/12) and vehicle (n = 10/12). No other adverse events were observed. CONCLUSION A CGM-guided closed-loop rescue system can detect imminent hypoglycemia and deliver glucagon, reducing severe hypoglycemia in PBH. CLINICAL TRIALS REGISTRATION NCT03255629.
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Affiliation(s)
| | - Stamatina Zavitsanou
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA
| | | | - David Pober
- Research Division, Joslin Diabetes Center, Boston, MA
| | | | | | - Ipsa Arora
- Research Division, Joslin Diabetes Center, Boston, MA
| | | | | | | | - Francis J Doyle
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA
| | - Eyal Dassau
- Research Division, Joslin Diabetes Center, Boston, MA
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA
- Correspondence and Reprint Requests: Mary-Elizabeth Patti, MD, 1 Joslin Place, Boston, MA 02215. E-mail: ; or Eyal Dassau, PhD, Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, 29 Oxford Street, Cambridge, MA, 02138. E-mail:
| | - Mary Elizabeth Patti
- Research Division, Joslin Diabetes Center, Boston, MA
- Correspondence and Reprint Requests: Mary-Elizabeth Patti, MD, 1 Joslin Place, Boston, MA 02215. E-mail: ; or Eyal Dassau, PhD, Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, 29 Oxford Street, Cambridge, MA, 02138. E-mail:
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21
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Evers SS, Kim KS, Bozadjieva N, Lewis AG, Farris D, Sorensen MJ, Kim Y, Whitesall SE, Kennedy RT, Michele DE, Seeley RJ, Sandoval DA. Continuous glucose monitoring reveals glycemic variability and hypoglycemia after vertical sleeve gastrectomy in rats. Mol Metab 2020; 32:148-159. [PMID: 32029224 PMCID: PMC7005148 DOI: 10.1016/j.molmet.2019.12.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 12/19/2022] Open
Abstract
Objective Post–bariatric surgery hypoglycemia (PBH) is defined as the presence of neuroglycopenic symptoms accompanied by postprandial hypoglycemia in bariatric surgery patients. Recent clinical studies using continuous glucose monitoring (CGM) technology revealed that PBH is more frequently observed in vertical sleeve gastrectomy (VSG) patients than previously recognized. PBH cannot be alleviated by current medication. Therefore, a model system to investigate the mechanism and treatment is required. Methods We used CGM in a rat model of VSG and monitored the occurrence of glycemic variability and hypoglycemia in various meal conditions for 4 weeks after surgery. Another cohort of VSG rats with CGM was used to investigate whether the blockade of glucagon-like peptide-1 receptor (GLP-1R) signaling alleviates these symptoms. A mouse VSG model was used to investigate whether the impaired glucose counterregulatory system causes postprandial hypoglycemia. Results Like in humans, rats have increased glycemic variability and hypoglycemia after VSG. Postprandial hypoglycemia was specifically detected after liquid versus solid meals. Further, the blockade of GLP-1R signaling raises the glucose nadir but does not affect glycemic variability. Conclusions Rat bariatric surgery duplicates many features of human post–bariatric surgery hypoglycemia including postprandial hypoglycemia and glycemic variability, while blockade of GLP-1R signaling prevents hypoglycemia but not the variability. VSG causes glycemic variability during ad lib feeding condition. Single liquid meal ingestion causes post-VSG hypoglycemia. Blockade of GLP-1 receptor prevents post-VSG hypoglycemia.
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Affiliation(s)
- Simon S Evers
- Department of Surgery, University of Michigan, Ann Arbor, MI 48105, USA
| | - Ki-Suk Kim
- Department of Surgery, University of Michigan, Ann Arbor, MI 48105, USA
| | | | - Alfor G Lewis
- Department of Surgery, University of Michigan, Ann Arbor, MI 48105, USA
| | - Diana Farris
- Department of Surgery, University of Michigan, Ann Arbor, MI 48105, USA
| | - Matthew J Sorensen
- Department of Chemistry, University of Michigan, Ann Arbor, MI 48105, USA
| | - Youngsoo Kim
- Department of Chemistry, University of Michigan, Ann Arbor, MI 48105, USA
| | - Steven E Whitesall
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI 48105, USA
| | - Robert T Kennedy
- Department of Chemistry, University of Michigan, Ann Arbor, MI 48105, USA
| | - Daniel E Michele
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI 48105, USA
| | - Randy J Seeley
- Department of Surgery, University of Michigan, Ann Arbor, MI 48105, USA
| | - Darleen A Sandoval
- Department of Surgery, University of Michigan, Ann Arbor, MI 48105, USA; Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48105, USA; Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI 48105, USA.
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22
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Sheehan A, Patti ME. Hypoglycemia After Upper Gastrointestinal Surgery: Clinical Approach to Assessment, Diagnosis, and Treatment. Diabetes Metab Syndr Obes 2020; 13:4469-4482. [PMID: 33239898 PMCID: PMC7682607 DOI: 10.2147/dmso.s233078] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/28/2020] [Indexed: 12/11/2022] Open
Abstract
CONTEXT Post-bariatric hypoglycemia (PBH) is an increasingly encountered complication of upper gastrointestinal surgery; the prevalence of this condition is anticipated to rise given yearly increases in bariatric surgical procedures. While PBH is incompletely understood, there is a growing body of research describing the associated factors, mechanisms, and treatment approaches for this condition. EVIDENCE ACQUISITION Data are integrated and summarized from studies of individuals affected by PBH and hypoglycemia following upper gastrointestinal surgery obtained from PubMed searches (1990-2020). EVIDENCE SYNTHESIS Information addressing etiology, incidence/prevalence, clinical characteristics, assessment, and treatment were reviewed and synthesized for the practicing physician. Literature reports were supplemented by clinical experience as indicated, when published data were not available. CONCLUSION PBH can be life-altering and severe for a subset of individuals. Given the chronic nature of this condition, and sequelae of both acute and recurrent episodes, increasing provider awareness of both the condition and associated risk factors is critical for assessment, prompt diagnosis, treatment, and preoperative identification of individuals at risk.
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Affiliation(s)
- Amanda Sheehan
- Research Division, Joslin Diabetes Center, Boston, MA, USA
| | - Mary Elizabeth Patti
- Research Division, Joslin Diabetes Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Correspondence: Mary Elizabeth Patti Research Division, Joslin Diabetes Center, 1 Joslin Place, Boston, MA02215, USATel +1 617-309-1966Fax +1 617-309-2593 Email
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Chen X, Kamel D, Barnett B, Yung E, Quinn A, Nguyen C. An unusual presentation of post gastric bypass hypoglycemia with both postprandial and fasting hypoglycemia. Endocrinol Diabetes Metab Case Rep 2018; 2018:18-0089. [PMID: 30427165 PMCID: PMC6215949 DOI: 10.1530/edm-18-0089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
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.
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Affiliation(s)
- Xin Chen
- Division of Internal Medicine, LAC+USC Medical Center, University of Southern California, Los Angeles, California, USA
| | - Dina Kamel
- Division of Endocrinology, Diabetes, and Metabolism, Keck School of Medicine, LAC+USC Medical Center, University of Southern California, Los Angeles, California, USA
| | - Braden Barnett
- Division of Endocrinology, Diabetes, and Metabolism, Keck School of Medicine, LAC+USC Medical Center, University of Southern California, Los Angeles, California, USA
| | - Evan Yung
- Division of Pathology, LAC+USC Medical Center, University of Southern California, Los Angeles, California, USA
| | - Adrienne Quinn
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - 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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24
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Salehi M, Vella A, McLaughlin T, Patti ME. Hypoglycemia After Gastric Bypass Surgery: Current Concepts and Controversies. J Clin Endocrinol Metab 2018; 103:2815-2826. [PMID: 30101281 PMCID: PMC6692713 DOI: 10.1210/jc.2018-00528] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 05/01/2018] [Indexed: 12/12/2022]
Abstract
CONTEXT Hypoglycemia, occurring after bariatric and other forms of upper gastrointestinal surgery, is increasingly encountered by clinical endocrinologists. The true frequency of this condition remains uncertain, due, in part, to differences in the diagnostic criteria and in the affected populations, as well as relative lack of patient and physician awareness and understanding of this condition. Postbariatric hypoglycemia can be severe and disabling for some patients, with neuroglycopenia (altered cognition, seizures, and loss of consciousness) leading to falls, motor vehicle accidents, and job and income loss. Moreover, repeated episodes of hypoglycemia can result in hypoglycemia unawareness, further impairing safety and requiring the assistance of others to treat hypoglycemia. OBJECTIVE In this review, we summarize and integrate data from studies of patients affected by hypoglycemia after Roux-en-Y gastric bypass (RYGB) surgery, obtained from PubMed searches (1990 to 2017) and reference searches of relevant retrieved articles. Whereas hypoglycemia can also be observed after sleeve gastrectomy and fundoplication, this review is focused on post-RYGB, given the greater body of published clinical studies at present. OUTCOME MEASURES Data addressing specific aspects of diagnosis, pathophysiology, and treatment were reviewed by the authors; when not available, the authors have provided opinions based on clinical experience with this challenging condition. CONCLUSIONS Hypoglycemia, occurring after gastric bypass surgery, is challenging for patients and physicians alike. This review provides a systematic approach to diagnosis and treatment based on the underlying pathophysiology.
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Affiliation(s)
- Marzieh Salehi
- Diabetes Division, University of Texas Health at San Antonio, San Antonio, Texas
| | | | | | - Mary-Elizabeth Patti
- Research and Clinic Divisions, Joslin Diabetes Center and Harvard Medical School, Boston, Massachusetts
- Correspondence and Reprint Requests: Mary-Elizabeth Patti, MD, Research and Clinic Divisions, Joslin Diabetes Center and Harvard Medical School, 1 Joslin Place, Boston, Massachusetts 02215. E-mail:
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25
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Ball CG, Grondin SC, Pasieka JL, Kirkpatrick AW, MacLean AR, Cantle P, Dixon E, Schneider P, Hamilton M. Examples of dramatic failures and their effectiveness in modern surgical disciplines: can we learn from our mistakes? J Comp Eff Res 2018; 7:709-720. [PMID: 29888953 DOI: 10.2217/cer-2017-0090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Innovation can be variably defined, but when applied to healthcare is often considered to be the introduction of something new, whether an idea, method or device, into an unfilled void or needy environment. Despite the introduction of many positive surgical subspecialty altering concepts/devices however, epic failures are not uncommon. These failures can be dramatic in regards to both their human and economic costs. They can also be very public or more quiet in nature. As surgical leaders in our communities and advocates for patient safety and outcomes, it remains crucial that we meet new introductions in technology and patient care with a measured level of curiosity, skepticism and science-based conclusions. The aim of an expert committee was to identify the most dominant failures in technological innovation and/or dogmatic clinical beliefs within each major surgical subspecialty. In summary, this effort was pursued to highlight the past failures and remind surgeons to remain vigilant and appropriately skeptical with regard to the introduction of new innovations and clinical beliefs within our craft.
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Affiliation(s)
- Chad G Ball
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Sean C Grondin
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Janice L Pasieka
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | | | - Anthony R MacLean
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Paul Cantle
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Elijah Dixon
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Prism Schneider
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Mark Hamilton
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,Department of Neurosciences, University of Calgary, Calgary, Alberta, Canada
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26
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Davis DB, Khoraki J, Ziemelis M, Sirinvaravong S, Han JY, Campos GM. Roux en Y gastric bypass hypoglycemia resolves with gastric feeding or reversal: Confirming a non-pancreatic etiology. Mol Metab 2018; 9:15-27. [PMID: 29449181 PMCID: PMC5869737 DOI: 10.1016/j.molmet.2017.12.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 12/14/2017] [Accepted: 12/18/2017] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Postprandial hypoglycemia is an infrequent but disabling complication of Roux-en-Y gastric bypass (RYGB) surgery. Controversy still exists as to whether the postprandial hyperinsulinemia observed is due to inherent changes in pancreatic β-cell mass or function or to reversible alterations caused by RYGB anatomy. We aimed to determine if gastric feeding or reversal of RYGB would normalize postprandial glucose and hormone excursions in patients with symptomatic hypoglycemia. METHODS We completed a prospective study of six patients with severe symptomatic RYGB hypoglycemia who underwent RYGB reversal. An additional subject without hypoglycemia who underwent RYGB reversal was also studied prospectively. Mixed meal tolerance testing (MTT) was done orally (RYGB anatomy), via gastrostomy tube in the excluded stomach in the setting of RYGB, and several months after RYGB reversal. RESULTS All subjects reported symptomatic improvement of hypoglycemia after reversal of RYGB. Weight gain after reversal was moderate and variable. Postprandial glucose, insulin, and GLP-1 excursions were significantly diminished with gastric feeding and after reversal. Insulin secretion changed proportional to glucose levels and insulin clearance increased after reversal. Glucagon/insulin ratios were similar throughout study. We further compared the impact of modified sleeve gastrectomy reversal surgery to those with restoration of complete stomach and found no significant differences in weight regain or in postprandial glucose or hormone levels. CONCLUSIONS Reversal of RYGB is an effective treatment option for severe postprandial hypoglycemia. The pathophysiology of this disorder is primarily due to RYGB anatomy resulting in altered glucose, gut, and pancreatic hormone levels and decreased insulin clearance, rather than inherent β-cell hyperplasia or hyperfunction.
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Affiliation(s)
- Dawn Belt Davis
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Wisconsin, 1685 Highland Avenue, Madison, WI, 53705, USA; William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, WI 53705, USA.
| | - Jad Khoraki
- Division of General Surgery, Department of Surgery, 600 Highland Avenue, University of Wisconsin, Madison, WI, 53705, USA; Division of Bariatric and Gastrointestinal Surgery, Department of Surgery, Virginia Commonwealth University, 1200 East Broad Street, Richmond, VA, 23298, USA
| | - Martynas Ziemelis
- Division of General Surgery, Department of Surgery, 600 Highland Avenue, University of Wisconsin, Madison, WI, 53705, USA
| | - Sirinart Sirinvaravong
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Wisconsin, 1685 Highland Avenue, Madison, WI, 53705, USA
| | - Jee Young Han
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Wisconsin, 1685 Highland Avenue, Madison, WI, 53705, USA
| | - Guilherme M Campos
- Division of General Surgery, Department of Surgery, 600 Highland Avenue, University of Wisconsin, Madison, WI, 53705, USA; Division of Bariatric and Gastrointestinal Surgery, Department of Surgery, Virginia Commonwealth University, 1200 East Broad Street, Richmond, VA, 23298, USA.
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27
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Affiliation(s)
- Ipsa Arora
- Research Division, Joslin Diabetes Center, Boston, MA, USA
| | - Mary-Elizabeth Patti
- Research Division, Joslin Diabetes Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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28
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Yaqub A, Smith EP, Salehi M. Hyperinsulinemic hypoglycemia after gastric bypass surgery: what's up and what's down? Int J Obes (Lond) 2017; 42:ijo2017257. [PMID: 29087389 PMCID: PMC6599543 DOI: 10.1038/ijo.2017.257] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 09/17/2017] [Accepted: 09/24/2017] [Indexed: 12/18/2022]
Abstract
Obesity is a global public health problem and attempts to treat this condition using life style with and without pharmacological interventions have not been successful in majority of obese individuals. To date, the most effective treatment for obesity is weight loss surgery. One of the most widely used procedures to treat obesity worldwide, Roux-en-Y gastric bypass surgery (RYGB), has shown to induce diabetes remission in addition to significant and sustainable weight loss. As the number of this procedure performed over the last two decades increased, it has become clear that a subgroup of individuals develop postprandial hypoglycemia several years after surgery. This debilitating late complication of RYGB is often associated with loss of consciousness or seizures, and in severe cases, it is only partially responsive to diet modification or other available therapeutic options. The diagnosis is often a challenge resulting in delays in receiving care in the affected individuals. Although the underlying mechanisms are under current investigations, growing evidence suggest that a combination of exaggerated meal-derived nutrient appearance to systemic circulation and altered islet and gut hormone response after eating have a role in pathogenesis of this condition. The goal of this review is to highlight new perspectives regarding this life-threatening complication of RYGB. The etiology, diagnosis, recommendation on how to distinguish from classic dumping and current available treatment based on literature review will be discussed. In addition, physiologic changes after gastric bypass predisposing to hypoglycemia syndrome will be highlighted.International Journal of Obesity advance online publication, 31 October 2017; doi:10.1038/ijo.2017.257.
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Affiliation(s)
- A Yaqub
- Division of Endocrinology, Department of Medicine, Diabetes and Metabolism, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - EP Smith
- Division of Endocrinology, Department of Medicine, Diabetes and Metabolism, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - M Salehi
- Division of Endocrinology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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29
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Adult Nesidioblastosis With Hypoglycemia Mimicking an Insulinoma: A Challenging Case. Int Surg 2017. [DOI: 10.9738/intsurg-d-17-00020.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: Nesidioblastosis is the primary cause of persistent hyperinsulinemic hypoglycemia in infants but it is a rare entity for the adults. Nesidioblastosis is defined as an increase of pancreatic beta cells in number and in size. Case Presentation: We describe a rare case of nesidioblastosis with positive endoscopic ultrasonography result mimicking an insulinoma. A 35-year-old female patient had hypoglycemic episodes with high insulin level. Her investigation revealed low venous plasma glucose, high insulin and C-peptide level with positive 72-hour fasting test suggestive of hyperinsulinemic hypoglycemia. Abdominal computed tomography did not show any mass lesion. Endoscopic ultrasonography revealed a mass lesion sized as 1 cm in diameter in the pancreas. But, insulinoma like lesion couldn't be found intra-operatively. It was decided to perform distal pancreatectomy. After distal pancreatectomy, nesidioblastosis was diagnosed histopathologically. The patient was free from her symptoms after surgery. Conclusion: This case illustrates difficulties and limitations of imaging modalities and false positive result of EUS in a case of nesidioblastosis. When there is no insulinoma like lesion during operation, operation should be performed as gradient guided pancreatectomy by the way of selective arterial calcium injection test.
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30
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Patti ME, Goldfine AB, Hu J, Hoem D, Molven A, Goldsmith J, Schwesinger WH, La Rosa S, Folli F, Kulkarni RN. Heterogeneity of proliferative markers in pancreatic β-cells of patients with severe hypoglycemia following Roux-en-Y gastric bypass. Acta Diabetol 2017; 54:737-747. [PMID: 28512677 PMCID: PMC5515485 DOI: 10.1007/s00592-017-1001-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/06/2017] [Indexed: 12/17/2022]
Abstract
AIMS Severe postprandial hypoglycemia with neuroglycopenia is an increasingly recognized, debilitating complication of Roux-en-Y gastric bypass (RYGB) surgery. Increased secretion of insulin and incretin hormones is implicated in its pathogenesis. Histopathologic examination of pancreas has demonstrated increased islet size and/or nuclear diameter in post-RYGB patients who underwent pancreatectomy for severe refractory hypoglycemia with neuroglycopenia (RYGB + NG). We aimed to determine whether β-cell proliferation or apoptosis is altered in RYGB + NG. METHODS We performed an observational study to analyze markers of proliferation, apoptosis, cell cycle, and transcription factor expression in pancreatic tissue from affected RYGB + NG patients (n = 12), normoglycemic patients undergoing pancreatic surgery for benign lesions (controls, n = 6), and individuals with hypoglycemia due to insulinoma (n = 52). RESULTS Proliferative cell nuclear antigen (PCNA) expression was increased in insulin-positive cells in RYGB + NG patients (4.5-fold increase, p < 0.001 vs. controls) and correlated with β-cell mass. Ki-67 immunoreactivity was low in both RYGB + NG and controls, but did not differ between groups. Phospho-histone H3 levels did not differ between RYGB + NG and controls. PCNA and Ki-67 were both significantly lower in both controls and RYGB + NG than insulinomas. Markers of apoptosis and cell cycle (M30, p27, and p21) did not differ between groups. PDX1 and menin exhibited similar expression patterns, while FOXO1 appeared to be more cytosolic in RYGB + NG. CONCLUSIONS Markers of proliferation are heterogeneous in patients with severe post-RYGB hypoglycemia. Increased β-cell proliferation in some individuals may contribute to increased β-cell mass observed in severely affected patients.
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Affiliation(s)
- Mary-Elizabeth Patti
- Research Division, Joslin Diabetes Center, and Harvard Medical School, 1 Joslin Place, Boston, MA, 02215, USA.
| | - Allison B Goldfine
- Research Division, Joslin Diabetes Center, and Harvard Medical School, 1 Joslin Place, Boston, MA, 02215, USA
| | - Jiang Hu
- Research Division, Joslin Diabetes Center, and Harvard Medical School, 1 Joslin Place, Boston, MA, 02215, USA
| | - Dag Hoem
- Department of Surgery, Haukeland University Hospital, 5021, Bergen, Norway
| | - Anders Molven
- Gade Laboratory for Pathology, Department of Clinical Medicine, University of Bergen, 5020, Bergen, Norway
- KG Jebsen Center for Diabetes Research, Department of Clinical Science, University of Bergen, 5020, Bergen, Norway
- Department of Pathology, Haukeland University Hospital, 5021, Bergen, Norway
| | - Jeffrey Goldsmith
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, 02115, USA
| | - Wayne H Schwesinger
- Department of Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA
| | - Stefano La Rosa
- Service of Clinical Pathology, Lausanne University Hospital, Institute of Pathology, 1011, Lausanne, Switzerland
| | - Franco Folli
- Department of Medicine, Division of Diabetes, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
- Faculdade de Ciencias Medicas (FCM), Departamento de Clinica Medica, Obesity and Comorbidities Research Center (O.C.R.C.), Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
- Endocrinology and Metabolic Diseases, Department of Health Sciences, University of Milano, Via A. Di Rudini', 8, 20149, Milan, Italy
| | - Rohit N Kulkarni
- Research Division, Joslin Diabetes Center, and Harvard Medical School, 1 Joslin Place, Boston, MA, 02215, USA.
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31
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Borbély YM, Osterwalder A, Kröll D, Nett PC, Inglin RA. Diarrhea after bariatric procedures: Diagnosis and therapy. World J Gastroenterol 2017; 23:4689-4700. [PMID: 28765690 PMCID: PMC5514634 DOI: 10.3748/wjg.v23.i26.4689] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 03/30/2017] [Accepted: 06/19/2017] [Indexed: 02/07/2023] Open
Abstract
Diarrhea after bariatric procedures, mainly those with malabsorptive elements including Roux-Y Gastric Bypass and Biliopancreatic Diversion, is common and an essential determinant of quality of life and micro- and macronutrient deficiencies. Bariatric surgery is the only sustainably successful method to address morbid obesity and its comorbidities, particularly gaining more and more importance in the specific treatment of diabetic patients. Approximately half a million procedures are annually performed around the world, with numbers expected to rise drastically in the near future. A multitude of factors exert their influence on bowel habits; preoperative comorbidities and procedure-related aspects are intertwined with postoperative nutritional habits. Diagnosis may be challenging owing to the characteristics of post-bariatric surgery anatomy with hindered accessibility of excluded segments of the small bowel and restriction at the gastric level. Conventional testing measures, if available, generally yield low accuracy and are usually not validated in this specific population. Limited trials of empiric treatment are a practical alternative and oftentimes an indispensable part of the diagnostic process. This review provides an overview of causes for chronic post-bariatric surgery diarrhea and details the particularities of its diagnosis and treatment in this specific patient population. Topics of current interest such as the impact of gut microbiota and the influence of bile acids on morbid obesity and especially their role in diarrhea are highlighted in order to provide a better understanding of the specific problems and chances of future treatment in post-bariatric surgery patients.
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32
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Kittah NE, Vella A. MANAGEMENT OF ENDOCRINE DISEASE: Pathogenesis and management of hypoglycemia. Eur J Endocrinol 2017; 177:R37-R47. [PMID: 28381450 DOI: 10.1530/eje-16-1062] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 03/15/2017] [Accepted: 04/05/2017] [Indexed: 01/03/2023]
Abstract
Glucose is the main substrate utilized by the brain and as such multiple regulatory mechanisms exist to maintain glucose concentrations. When these mechanisms fail or are defective, hypoglycemia ensues. Due to these robust mechanisms, hypoglycemia is uncommon and usually occurs in the setting of the treatment of diabetes using glucose-lowering agents such as sulfonylureas or insulin. The symptoms of hypoglycemia are non-specific and as such it is important to confirm hypoglycemia by establishing the presence of Whipple's triad before embarking on an evaluation for hypoglycemia. When possible, evaluation of hypoglycemia should be carried out at the time of spontaneous occurrence of symptoms. If this is not possible then one would want to create the circumstances under which symptoms occur. In cases where symptoms occur in the post absorptive state, a 72-h fast should be performed. Likewise, if symptoms occur after a meal then a mixed meal study may be the test of choice. The causes of endogenous hyperinsulinemic hypoglycemia include insulinoma, post-bariatric hypoglycemia and noninsulinoma pancreatogenous hypoglycemia syndrome. Autoimmune hypoglycemia syndrome is clinically and biochemically similar to insulinoma but associated with high levels of insulin antibodies and plasma insulin. Other important causes of hypoglycemia include medications, non-islet cell tumors, hormonal deficiencies, critical illness and factitious hypoglycemia. We provide an overview of the pathogenesis and management of hypoglycemia in these situations.
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Affiliation(s)
- Nana Esi Kittah
- Division of EndocrinologyDiabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Adrian Vella
- Division of EndocrinologyDiabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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van Beek AP, Emous M, Laville M, Tack J. Dumping syndrome after esophageal, gastric or bariatric surgery: pathophysiology, diagnosis, and management. Obes Rev 2017; 18:68-85. [PMID: 27749997 DOI: 10.1111/obr.12467] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/04/2016] [Accepted: 07/26/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Dumping syndrome, a common complication of esophageal, gastric or bariatric surgery, includes early and late dumping symptoms. Early dumping occurs within 1 h after eating, when rapid emptying of food into the small intestine triggers rapid fluid shifts into the intestinal lumen and release of gastrointestinal hormones, resulting in gastrointestinal and vasomotor symptoms. Late dumping occurs 1-3 h after carbohydrate ingestion, caused by an incretin-driven hyperinsulinemic response resulting in hypoglycemia. Clinical recommendations are needed for the diagnosis and management of dumping syndrome. METHODS A systematic literature review was performed through February 2016. Evidence-based medicine was used to develop diagnostic and management strategies for dumping syndrome. RESULTS Dumping syndrome should be suspected based on concurrent presentation of multiple suggestive symptoms after upper abdominal surgery. Suspected dumping syndrome can be confirmed using symptom-based questionnaires, glycemia measurements and oral glucose tolerance tests. First-line management of dumping syndrome involves dietary modification, as well as acarbose treatment for persistent hypoglycemia. If these approaches are unsuccessful, somatostatin analogues should be considered in patients with dumping syndrome and impaired quality of life. Surgical re-intervention or continuous enteral feeding may be necessary for treatment-refractory dumping syndrome, but outcomes are variable. CONCLUSIONS Implementation of these diagnostic and treatment recommendations may improve dumping syndrome management.
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Affiliation(s)
- A P van Beek
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - M Emous
- Department of Bariatric and Metabolic Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - M Laville
- European Center for Nutrition and Health (CENS), University of Lyon, 1 Civil Hospices of Lyon, Lyon, France
| | - J Tack
- Department of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium
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34
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Davi MV, Pia A, Guarnotta V, Pizza G, Colao A, Faggiano A. The treatment of hyperinsulinemic hypoglycaemia in adults: an update. J Endocrinol Invest 2017; 40:9-20. [PMID: 27624297 DOI: 10.1007/s40618-016-0536-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 08/17/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Treatment of hyperinsulinemic hypoglycaemia (HH) is challenging due to the rarity of this condition and the difficulty of differential diagnosis. The aim of this article is to give an overview of the recent literature on the management of adult HH. METHODS A search for reviews, original articles, original case reports between 1995 and 2016 in PubMed using the following keywords: hyperinsulinemic hypoglycaemia, insulinoma, nesidioblastosis, gastric bypass, autoimmune hypoglycaemia, hyperinsulinism, treatment was performed. RESULTS One hundred and forty articles were selected and analysed focusing on the most recent treatments of HH. CONCLUSIONS New approaches to treatment of HH are available including mini-invasive surgical techniques and alternative local-regional ablative therapy for benign insulinoma and everolimus for malignant insulinoma. A correct differential diagnosis is of paramount importance to avoid unnecessary surgical operations and to implement the appropriate treatment mainly in the uncommon forms of HH, such as nesidioblastosis and autoimmune hypoglycaemia.
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Affiliation(s)
- M V Davi
- Section of Endocrinology, Medicina Generale e Malattie Aterotrombotiche e Degenerative, Department of Medicine, University of Verona, Piazzale LA Scuro, Policlinico G.B. Rossi, 37134, Verona, Italy.
| | - A Pia
- Internal Medicine I, Department of Clinical and Biological Sciences, University of Turin, San Luigi Hospital, Orbassano, Italy
| | - V Guarnotta
- Section of Endocrinology, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Palermo, Italy
| | - G Pizza
- Endocrinology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - A Colao
- Endocrinology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - A Faggiano
- Thyroid and Parathyroid Surgery Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione G. Pascale" IRCCS, Naples, Italy
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35
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Eisenberg D, Azagury DE, Ghiassi S, Grover BT, Kim JJ. ASMBS Position Statement on Postprandial Hyperinsulinemic Hypoglycemia after Bariatric Surgery. Surg Obes Relat Dis 2016; 13:371-378. [PMID: 28110984 DOI: 10.1016/j.soard.2016.12.005] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 12/07/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Dan Eisenberg
- Department of Surgery, Stanford School of Medicine, Stanford, California; Department of Surgery, Palo Alto VA Health Care System, Palo Alto, California.
| | - Dan E Azagury
- Section of Bariatric and Minimally Invasive Surgery, Stanford University School of Medicine, Stanford, California
| | - Saber Ghiassi
- Yale School of Medicine, New Haven, Connecticut; Department of Surgery, Bridgeport Hospital, Fairfield, Connecticut
| | - Brandon T Grover
- Department of Surgery, Gundersen Health System, La Crosse, Wisconsin
| | - Julie J Kim
- Department of General Surgery, Tufts University School of Medicine, Boston, Massachusetts
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36
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Anderson B, Nostedt J, Girgis S, Dixon T, Agrawal V, Wiebe E, Senior PA, Shapiro AMJ. Insulinoma or non-insulinoma pancreatogenous hypoglycemia? A diagnostic dilemma. J Surg Case Rep 2016; 2016:rjw188. [PMID: 27887024 PMCID: PMC5159181 DOI: 10.1093/jscr/rjw188] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Insulinoma is the most common cause of endogenous hyperinsulinemic hypoglycemia in adults. An alternate etiology, non-insulinoma pancreatogenous hypoglycemia (NIPH), is rare. Clinically, NIPH is characterized by postprandial hyperinsulinemic hypoglycemia, negative 72-h fasts, negative preoperative localization studies for insulinoma and positive selective arterial calcium infusion tests. Histologically, diffuse islet hyperplasia with increased number and size of islet cells is present and confirms the diagnosis. Differentiating NIPH from occult insulinoma preoperatively is challenging. Partial pancreatectomy is the procedure of choice; however, recurrence of symptoms, although less debilitating, occurs commonly. Medical management with diazoxide, verapamil and octreotide can be used for persistent symptoms. Ultimately, near-total or total pancreatectomy may be necessary. We report a case of a 67-year-old male with hypoglycemia in whom preoperative workup, including computerized tomography abdomen, suggested insulinoma, but whose final diagnosis on pathology was NIPH instead.
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Affiliation(s)
- Blaire Anderson
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Jordan Nostedt
- Department of Surgery, University of Alberta, Edmonton, Canada
| | - Safwat Girgis
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Canada
| | - Tara Dixon
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Canada
| | - Veena Agrawal
- Department of Medicine, Division of Endocrinology and Metabolism, University of Alberta, Edmonton, Canada
| | - Edward Wiebe
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Canada
| | - Peter A Senior
- Department of Medicine, Division of Endocrinology and Metabolism, University of Alberta, Edmonton, Canada
| | - A M James Shapiro
- Department of Surgery, University of Alberta, Edmonton, Canada .,Department of Medicine, Division of Endocrinology and Metabolism, University of Alberta, Edmonton, Canada
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Shantavasinkul PC, Torquati A, Corsino L. Post-gastric bypass hypoglycaemia: a review. Clin Endocrinol (Oxf) 2016; 85:3-9. [PMID: 26840207 DOI: 10.1111/cen.13033] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 11/27/2015] [Accepted: 01/28/2016] [Indexed: 12/27/2022]
Abstract
Bariatric surgery is a highly effective treatment for severe obesity, resulting in substantial weight loss and normalizing obesity-related comorbidities. However, long-term consequences can occur, such as postbariatric surgery hypoglycaemia. This is a challenging medical problem, and the number of patients presenting with it has been increasing. Roux-en-Y gastric bypass (RYGB) is the most popular bariatric procedure, and it is the surgery most commonly associated with the development of postbariatric surgery hypoglycaemia. To date, the pathogenesis of this condition has not been completely established. However, various factors - particularly increased postprandial glucagon-like peptide (GLP)-1 secretion - have been considered as crucial mediator. The mechanisms responsible for diabetic remission after bariatric surgery may be responsible for the development of hypoglycaemia, which typically occurs 1-3 h after a meal and is concurrent with inappropriate hyperinsulinaemia. Carbohydrate-rich foods usually provoke hypoglycaemic symptoms, which can typically be alleviated by strict dietary modifications, including carbohydrate restriction and avoidance of high glycaemic index foods and simple sugars. Few patients require further medical intervention, such as medications, but some patients have required a pancreatectomy. Because this option is not always successful, it is no longer routinely recommended. Clinical trials are needed to further determine the pathophysiology of this condition as well as the best diagnostic and treatment approaches for these patients.
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Affiliation(s)
- Prapimporn C Shantavasinkul
- Division of Nutrition and Biochemical Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Alfonso Torquati
- Center for Weight Loss and Bariatric Surgery, Department of General Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Leonor Corsino
- Department of Medicine, Division of Endocrinology, Metabolism and Nutrition, Duke University, Durham, NC, USA
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Kandaswamy L, Raghavan R, Pappachan JM. Spontaneous hypoglycemia: diagnostic evaluation and management. Endocrine 2016; 53:47-57. [PMID: 26951054 DOI: 10.1007/s12020-016-0902-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 02/15/2016] [Indexed: 02/07/2023]
Abstract
Spontaneous hypoglycemia is a puzzling clinical problem and an important reason for referral to endocrinologists. Several clinical conditions such as insulinomas, non-insulinoma pancreatogenous hypoglycemia syndrome, insulin autoimmune syndrome, postprandial hypoglycemia (reactive hypoglycemia), non-islet cell tumor hypoglycemia, primary adrenal insufficiency, hypopituitarism, and critical illness can be associated with spontaneous hypoglycemia. Rarely, in patients with mental health issues, factious hypoglycemia from extrinsic insulin use or ingestion of oral hypoglycemic agents can obfuscate the clinical picture for clinicians trying to identify an organic cause. In those presenting with Whipple's triad (symptoms ± signs of hypoglycemia, low plasma glucose, and resolution symptoms ± signs after hypoglycemia correction), a 72-h supervised fast test with measurement of plasma insulin, c-peptide, pro-insulin, and beta-hydroxybutyrate levels, coupled with plasma/urine sulphonylurea screen, forms the first step in diagnostic evaluation. A mixed meal test is preferable for those with predominantly postprandial symptoms. Additional non-invasive and/or invasive diagnostic evaluation is necessary if an organic hypoglycemic disorder is suspected. With the aid of a few brief clinical case scenarios, we discuss the diagnostic evaluation and management of spontaneous hypoglycemia through this comprehensive article.
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Affiliation(s)
- Leelavathy Kandaswamy
- Department of Endocrinology & Diabetes, New Cross Hospital, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP, UK
| | - Rajeev Raghavan
- Department of Endocrinology & Diabetes, New Cross Hospital, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP, UK
| | - Joseph M Pappachan
- Department of Endocrinology & Diabetes, New Cross Hospital, The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP, UK.
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Thompson SM, Vella A, Thompson GB, Rumilla KM, Service FJ, Grant CS, Andrews JC. Selective Arterial Calcium Stimulation With Hepatic Venous Sampling Differentiates Insulinoma From Nesidioblastosis. J Clin Endocrinol Metab 2015; 100:4189-97. [PMID: 26312578 PMCID: PMC4702445 DOI: 10.1210/jc.2015-2404] [Citation(s) in RCA: 39] [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: 01/26/2023]
Abstract
CONTEXT In adult patients with endogenous hyperinsulinemic hypoglycemia and negative or inconclusive noninvasive imaging, insulinoma and non-insulinoma pancreatogenous hypoglycemic syndrome (NIPHS) resulting from diffuse nesidioblastosis must be considered in the differential diagnosis. It is not known whether the biochemical results of selective arterial calcium stimulation (SACST) with hepatic venous sampling can differentiate insulinoma from diffuse nesidioblastosis. OBJECTIVE To determine the specificity of SACST with hepatic venous sampling in differentiating insulinoma from diffuse nesidioblastosis. DESIGN Retrospective review (January 1996 to March 2014). SETTING Tertiary referral center. PATIENTS OR OTHER PARTICIPANTS A total of 116 patients with biochemical evidence of endogenous hyperinsulinemic hypoglycemia and negative or inconclusive noninvasive imaging who were subsequently shown at surgery to have insulinoma (n = 42) or nesidioblastosis (n = 74) after undergoing SACST with hepatic venous sampling. INTERVENTION(S) SACST with hepatic venous sampling before pancreatic exploration. MAIN OUTCOME MEASURE(S) Receiver operating characteristic curves were generated from the biochemical results of SACST to determine the specificity of the maximum hepatic venous insulin concentration (mHVI) and the relative-fold increase in hepatic venous insulin concentration (rHVI) over baseline after calcium injection from the dominant artery in differentiating insulinoma from nesidioblastosis. RESULTS The mHVI (21.5-fold; P < .001) and rHVI (3.9-fold; P < .001) were significantly higher in the insulinoma group compared to the nesidioblastosis group. The areas under the receiver operating characteristic curve for mHVI and rHVI were excellent (0.94; P < .0001) and good (0.83; P < .0001), respectively, for differentiating insulinoma from nesidioblastosis. mHVI cutoffs of > 91.5 and > 263.5 μIU/mL were 95 and 100% specific for insulinoma, respectively. A 19-fold increase in rHVI over baseline was 99% specific for insulinoma. CONCLUSIONS These data suggest that the mHVI and rHVI at SACST may be useful in differentiating insulinoma from nesidioblastosis with high specificity in patients with hyperinsulinemic hypoglycemia and negative or inconclusive noninvasive imaging.
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Affiliation(s)
- Scott M Thompson
- Department of Radiology (S.M.T., J.C.A.), Department of Surgery (S.M.T., G.B.T., C.S.G.), Division of Endocrinology, Diabetes, and Metabolism (A.V., F.J.S.), and Department of Laboratory Medicine and Pathology (K.M.R.), College of Medicine, Mayo Clinic, Rochester, Minnesota 55905
| | - Adrian Vella
- Department of Radiology (S.M.T., J.C.A.), Department of Surgery (S.M.T., G.B.T., C.S.G.), Division of Endocrinology, Diabetes, and Metabolism (A.V., F.J.S.), and Department of Laboratory Medicine and Pathology (K.M.R.), College of Medicine, Mayo Clinic, Rochester, Minnesota 55905
| | - Geoffrey B Thompson
- Department of Radiology (S.M.T., J.C.A.), Department of Surgery (S.M.T., G.B.T., C.S.G.), Division of Endocrinology, Diabetes, and Metabolism (A.V., F.J.S.), and Department of Laboratory Medicine and Pathology (K.M.R.), College of Medicine, Mayo Clinic, Rochester, Minnesota 55905
| | - Kandelaria M Rumilla
- Department of Radiology (S.M.T., J.C.A.), Department of Surgery (S.M.T., G.B.T., C.S.G.), Division of Endocrinology, Diabetes, and Metabolism (A.V., F.J.S.), and Department of Laboratory Medicine and Pathology (K.M.R.), College of Medicine, Mayo Clinic, Rochester, Minnesota 55905
| | - F John Service
- Department of Radiology (S.M.T., J.C.A.), Department of Surgery (S.M.T., G.B.T., C.S.G.), Division of Endocrinology, Diabetes, and Metabolism (A.V., F.J.S.), and Department of Laboratory Medicine and Pathology (K.M.R.), College of Medicine, Mayo Clinic, Rochester, Minnesota 55905
| | - Clive S Grant
- Department of Radiology (S.M.T., J.C.A.), Department of Surgery (S.M.T., G.B.T., C.S.G.), Division of Endocrinology, Diabetes, and Metabolism (A.V., F.J.S.), and Department of Laboratory Medicine and Pathology (K.M.R.), College of Medicine, Mayo Clinic, Rochester, Minnesota 55905
| | - James C Andrews
- Department of Radiology (S.M.T., J.C.A.), Department of Surgery (S.M.T., G.B.T., C.S.G.), Division of Endocrinology, Diabetes, and Metabolism (A.V., F.J.S.), and Department of Laboratory Medicine and Pathology (K.M.R.), College of Medicine, Mayo Clinic, Rochester, Minnesota 55905
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40
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Total pancreatectomy for the management of refractory post-gastric bypass hypoglycemia. Dig Dis Sci 2015; 60:1505-9. [PMID: 25344909 DOI: 10.1007/s10620-014-3408-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 10/15/2014] [Indexed: 12/19/2022]
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Thompson SM, Vella A, Service FJ, Grant CS, Thompson GB, Andrews JC. Impact of variant pancreatic arterial anatomy and overlap in regional perfusion on the interpretation of selective arterial calcium stimulation with hepatic venous sampling for preoperative localization of occult insulinoma. Surgery 2015; 158:162-72. [PMID: 25873534 DOI: 10.1016/j.surg.2015.03.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Revised: 02/25/2015] [Accepted: 03/07/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND To determine the impact of variant pancreatic arterial anatomy and overlap in regional perfusion on the interpretation of selective arterial calcium stimulation (SACST) with hepatic venous sampling for preoperative localization of occult insulinoma. METHODS An institutional review board-approved retrospective review was undertaken of 42 patients with surgically confirmed, occult insulinoma who underwent SACST from January 1996 to March 2014. Location of the insulinoma was predicted initially based on the biochemical results of SACST alone according to Doppman's criteria. Pancreatic arteriograms were reviewed blinded to the biochemical results and the regional perfusion of each artery assessed. The anatomic and perfusion data were combined with the biochemical results to make a second prediction and compared with the surgical findings. RESULTS The biochemical results were positive in 1, 2, and 3 arterial distributions in 73.8%, 21.4%, and 4.8% of patients, respectively. The celiac trunk and superior mesenteric artery (SMA) anatomy were aberrant in 38.1% and 35.7% of patients, respectively. Clinically significant variations included dorsal pancreatic artery replaced to SMA (21.4%) and celiac stenosis (4.8%). Significant variation and overlap in regional pancreatic perfusion was observed, particularly for the SMA. Sensitivity for insulinoma localization was 54.8% (diagnostic arteriography), 73.8% (biochemical data), 88.1% (biochemical, anatomic, perfusion data), and 92.8% (arteriographic, biochemical, anatomic, perfusion data). CONCLUSION Careful review of the pancreatic arterial anatomy and regional perfusion is critical for correct interpretation of the biochemical results of SACST and improves the sensitivity of localization for occult insulinoma, particularly in the presence of pancreatic arterial variants or overlap in regional perfusion.
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Kriger AG, Smirnov AV, Kalinin DV, Glotov AV, Berelavichus SV, Konyaeva GI, Lebedeva AN, Karel'skaya NA, Tsygankov VN. [Nesidioblastosis (diagnosis, surgical treatment)]. Khirurgiia (Mosk) 2015:16-29. [PMID: 26978464 DOI: 10.17116/hirurgia20151016-29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Nesidioblastosis (NB) is rare disease with organic hyperinsulinism syndrome and caused by diffuse hyperplasia and/or hypertrophy of pancreatic islands of Langerhans. MATERIAL AND METHODS The results of surgical treatment of 3 patients with NB are presented. In all patients the diagnosis was suspected at the preoperative stage and confirmed by histological examination later. Herewith in 2 patients NB was combined with insulinoma. All patients underwent corpora-caudal pancreatectomy. RESULTS In postoperative period one patient hadn't episodes of hypoglycemia for the entire follow-up period (5 months), in another patient hypoglycemic states occurred at 1.5 months after surgery. The third patient required pancreatic head extirpation at 11 days after surgery due to persistent severe course of organic hyperinsulinism. In immediate postoperative period in the same patient hyperinsular hypoglycemia was observed that pointed on extrapancreatic source of insulin secretion. However contrast-enhanced CT did not reveal any formations. CONCLUSION Thus, corpora-caudal pancreatectomy is preferable as surgical treatment. Results of surgical management can provide a complete regression of the symptoms, but do not guarantee absence of recurrence and even any changes in frequency and severity of hypoglycemic states.
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Affiliation(s)
- A G Kriger
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | - A V Smirnov
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | - D V Kalinin
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | - A V Glotov
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | - S V Berelavichus
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | | | - A N Lebedeva
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | - N A Karel'skaya
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
| | - V N Tsygankov
- A.V. Vishnevskiy Institute of Surgery, Health Ministry of the Russian Federation, Moscow
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Kefurt R, Langer FB, Schindler K, Shakeri-Leidenmühler S, Ludvik B, Prager G. Hypoglycemia after Roux-En-Y gastric bypass: detection rates of continuous glucose monitoring (CGM) versus mixed meal test. Surg Obes Relat Dis 2014; 11:564-9. [PMID: 25737101 DOI: 10.1016/j.soard.2014.11.003] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Revised: 11/02/2014] [Accepted: 11/03/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND Neuroglucopenic hypoglycemia might be an underestimated threat for roux-en-Y gastric bypass (RYGB) patients leading to fatigue, syncope, seizures or even accidental deaths. Different measurements can assess hypoglycemia such as a finger-stick glucometer, an Oral Glucose Tolerance Test, a Mixed Meal-Test (MMT) or, as introduced recently, continuous glucose monitoring (CGM). SETTING University Hospital, Austria. METHODS To assess the incidence of hypoglycemic episodes under real life conditions, 5-day CGM was performed in a series of 40 patients at a mean of 86 months after RYGB. The detection rates were compared to a mixed meal-test. RESULTS CGM detected hypoglycemic episodes of <55 mg/dL or <3.05 mmol/L in 75% of the patients, while MMT indicated hypoglycemia in 29% of the patients. CGM also detected nocturnal hypoglycemic episodes in 15 (38%) of the patients. A mean of 3±1 hypoglycemic episodes per patient with a mean duration of 71±25 minutes were observed by CGM. CONCLUSIONS Assessed under real life conditions by CGM, post-RYGB hypoglycemia was found more frequently than expected. CGM revealed hypoglycemic episodes in 75% of the patients while MMT had a lower detection rate. Thus, CGM may have a role for screening but also for the evaluation of dietary modifications, drug therapy or surgical intervention for hypoglycemia after RYGB.
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Affiliation(s)
- Ronald Kefurt
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Felix B Langer
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Karin Schindler
- Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | | | - Bernhard Ludvik
- Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Gerhard Prager
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Vienna, Austria.
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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.
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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
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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.
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Affiliation(s)
- Tom Mala
- Department of Morbid Obesity and Bariatric Surgery/Department of Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway.
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