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Post–Gastric Bypass Hypoglycemia

  • Hospital Management of Diabetes (GE Umpierrez, Section Editor)
  • Published:
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Abstract

Obesity is a major public health problem worldwide. Obesity-related illnesses, such as coronary heart disease, type 2 diabetes, hypertension, dyslipidemia, stroke, sleep apnea, and several forms of cancer (endometrial, breast, and colon), contribute to a significant number of deaths in the USA. Bariatric surgery, including the Roux-en-Y gastric bypass (RYGB) procedure, has demonstrated significant improvements in obesity and obesity-related co-morbidities and is becoming more popular as the number of obese individuals rises. Despite the reported benefits of bariatric surgery, there are potential complications that physicians need to be aware of as the number of patients undergoing these procedures continues to increase. One challenging and potentially life-threatening complication that to date is not well understood is post-RYGB surgery hypoglycemia (PGBH). In this review, we will present the definition, historical perspective, diagnostic approach, currently available treatment options, and anecdotal assessment and treatment algorithm for this disorder.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance,•• Of major importance

  1. Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9945):766–81.

    Article  PubMed Central  PubMed  Google Scholar 

  2. Ogden CL, Carroll MD, Kit BK, et al. Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA. 2014;311(8):806–14.

    Article  CAS  PubMed  Google Scholar 

  3. Finkelstein EA, Trogdon JG, Cohen JW, et al. Annual medical spending attributable to obesity: payer-and service-specific estimates. Health Aff (Millwood). 2009;28(5):w822–31.

    Article  Google Scholar 

  4. CDC. Adult obesity facts. 2014; Available from: http://www.cdc.gov/obesity/data/adult.html.

  5. Flegal KM, Graubard BI, Williamson DF, et al. Excess deaths associated with underweight, overweight, and obesity. JAMA. 2005;293(15):1861–7.

    Article  CAS  PubMed  Google Scholar 

  6. Sjostrom L. Review of the key results from the Swedish Obese Subjects (SOS) trial - a prospective controlled intervention study of bariatric surgery. J Intern Med. 2013;273(3):219–34. One of the first large scale studies that describe the prevalence rate of PGBH, though it is still likely that the rate is low in part due to inadequate recognition.

    Article  CAS  PubMed  Google Scholar 

  7. Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012;366(17):1567–76.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  8. Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012;366(17):1577–85.

    Article  CAS  PubMed  Google Scholar 

  9. Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357(8):753–61.

    Article  CAS  PubMed  Google Scholar 

  10. Cui Y, Elahi D, Andersen DK. Advances in the etiology and management of hyperinsulinemic hypoglycemia after Roux-en-Y gastric bypass. J Gastrointest Surg. 2011;15(10):1879–88.

    Article  PubMed  Google Scholar 

  11. Buchwald H, Oien DM. Metabolic/bariatric surgery Worldwide 2008. Obes Surg. 2009;19(12):1605–11.

    Article  PubMed  Google Scholar 

  12. Patti ME, McMahon G, Mun EC, et al. Severe hypoglycaemia post-gastric bypass requiring partial pancreatectomy: evidence for inappropriate insulin secretion and pancreatic islet hyperplasia. Diabetologia. 2005;48(11):2236–40.

    Article  CAS  PubMed  Google Scholar 

  13. Service GJ, Thompson GB, Service FJ, et al. Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric-bypass surgery. N Engl J Med. 2005;353(3):249–54.

    Article  CAS  PubMed  Google Scholar 

  14. Marsk R, Jonas E, Rasmussen F, et al. Nationwide cohort study of post-gastric bypass hypoglycaemia including 5,040 patients undergoing surgery for obesity in 1986–2006 in Sweden. Diabetologia. 2010;53(11):2307–11.

    Article  CAS  PubMed  Google Scholar 

  15. Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357(8):741–52.

    Article  PubMed  Google Scholar 

  16. Lee CJ, Clark JM, Schweitzer M, et al. Prevalence of and risk factors for hypoglycemic symptoms after gastric bypass and sleeve gastrectomy. Obesity (Silver Spring). 2015;23(5):1079–84. This study is one of the first larger studies to report prevalence and associated risk factors for PGBH with an emphasis on recognition of symptoms of hypoglycemia.

    Article  Google Scholar 

  17. Vella A, Service FJ. Incretin hypersecretion in post-gastric bypass hypoglycemia--primary problem or red herring? J Clin Endocrinol Metab. 2007;92(12):4563–5.

    Article  CAS  PubMed  Google Scholar 

  18. Won JG, Tseng HS, Yang AH, et al. Clinical features and morphological characterization of 10 patients with noninsulinoma pancreatogenous hypoglycaemia syndrome (NIPHS). Clin Endocrinol (Oxf). 2006;65(5):566–78.

    Article  Google Scholar 

  19. Service FJ, Natt N, Thompson GB, et al. Noninsulinoma pancreatogenous hypoglycemia: a novel syndrome of hyperinsulinemic hypoglycemia in adults independent of mutations in Kir6.2 and SUR1 genes. J Clin Endocrinol Metab. 1999;84(5):1582–9.

    CAS  PubMed  Google Scholar 

  20. Service FJ. Recurrent hyperinsulinemic hypoglycemia caused by an insulin-secreting insulinoma. Nat Clin Pract Endocrinol Metab. 2006;2(8):467–70. quiz following 470.

    Article  PubMed  Google Scholar 

  21. Placzkowski KA, Vella A, Thompson GB, et al. Secular trends in the presentation and management of functioning insulinoma at the Mayo Clinic, 1987–2007. J Clin Endocrinol Metab. 2009;94(4):1069–73.

    Article  CAS  PubMed  Google Scholar 

  22. Shealy RM, Simpson Jr WM, Lee FW, et al. The gaping hole: physicians are missing from the front line of disaster preparedness training. J S C Med Assoc. 2006;102(1):11–3.

    PubMed  Google Scholar 

  23. Cryer PE, Axelrod L, Grossman AB, et al. Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2009;94(3):709–28.

    Article  CAS  PubMed  Google Scholar 

  24. Melmed S, Williams RH, 1897. Williams textbook of endocrinology. 12th ed. Philadelphia: Elsevier/Saunders; 2011. p. 1897. xviii.

    Google Scholar 

  25. Foster-Schubert KE. Hypoglycemia complicating bariatric surgery: incidence and mechanisms. Curr Opin Endocrinol Diabetes Obes. 2011;18(2):129–33.

    Article  PubMed Central  PubMed  Google Scholar 

  26. Deitel M. The change in the dumping syndrome concept. Obes Surg. 2008;18(12):1622–4.

    Article  PubMed  Google Scholar 

  27. Meier JJ, Butler AE, Galasso R, et al. Hyperinsulinemic hypoglycemia after gastric bypass surgery is not accompanied by islet hyperplasia or increased beta-cell turnover. Diabetes Care. 2006;29(7):1554–9.

    Article  PubMed  Google Scholar 

  28. Goldfine AB, Mun EC, Devine E, et al. Patients with neuroglycopenia after gastric bypass surgery have exaggerated incretin and insulin secretory responses to a mixed meal. J Clin Endocrinol Metab. 2007;92(12):4678–85.

    Article  CAS  PubMed  Google Scholar 

  29. McLaughlin T, Peck M, Holst J, et al. Reversible hyperinsulinemic hypoglycemia after gastric bypass: a consequence of altered nutrient delivery. J Clin Endocrinol Metab. 2010;95(4):1851–5.

    Article  CAS  PubMed  Google Scholar 

  30. Cummings DE. Gastric bypass and nesidioblastosis--too much of a good thing for islets? N Engl J Med. 2005;353(3):300–2.

    Article  CAS  PubMed  Google Scholar 

  31. Toft-Nielsen M, Madsbad S, Holst JJ. Exaggerated secretion of glucagon-like peptide-1 (GLP-1) could cause reactive hypoglycaemia. Diabetologia. 1998;41(10):1180–6.

    Article  CAS  PubMed  Google Scholar 

  32. Salehi M, Prigeon RL, D’Alessio DA. Gastric bypass surgery enhances glucagon-like peptide 1-stimulated postprandial insulin secretion in humans. Diabetes. 2011;60(9):2308–14.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  33. Salehi M, Gastaldelli A, D’Alessio DA. Blockade of glucagon-like peptide 1 receptor corrects postprandial hypoglycemia after gastric bypass. Gastroenterology. 2014;146(3):669–680 e2. Elegant trial in which a GLP-1 receptor antagonist was used to show that PGBH was corrected after administration. Thus, both providing support to the hypothesis that PGBH is at least in part mediated by excess GLP-1 and also serve as a possible treatment strategy for these patients.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  34. Liou AP, Paziuk M, Jr Luevano JM, et al. Conserved shifts in the gut microbiota due to gastric bypass reduce host weight and adiposity. Sci Transl Med. 2013;5(178):178ra41.

    Article  PubMed Central  PubMed  Google Scholar 

  35. Patti ME, Houten SM, Bianco AC, et al. Serum bile acids are higher in humans with prior gastric bypass: potential contribution to improved glucose and lipid metabolism. Obesity (Silver Spring). 2009;17(9):1671–7.

    Article  CAS  Google Scholar 

  36. Cummings DE, Weigle DS, Frayo RS, et al. Plasma ghrelin levels after diet-induced weight loss or gastric bypass surgery. N Engl J Med. 2002;346(21):1623–30.

    Article  PubMed  Google Scholar 

  37. Lev-Ran A, Anderson RW. The diagnosis of postprandial hypoglycemia. Diabetes. 1981;30(12):996–9.

    Article  CAS  PubMed  Google Scholar 

  38. Kefurt R, Langer FB, Schindler K, et al. Hypoglycemia after Roux-En-Y gastric bypass: detection rates of continuous glucose monitoring (CGM) versus mixed meal test. Surg Obes Relat Dis. 2015;11(3):564–9. There are challenges to mixed meal testing in the diagnosis of PGBH. This study provides data to support the use of continuous glucose monitoring under real-life conditions to aid in the diagnosis and evaluation of therapy for PGBH.

    Article  PubMed  Google Scholar 

  39. Wiesli P, Brandle M, Schmid C, et al. Selective arterial calcium stimulation and hepatic venous sampling in the evaluation of hyperinsulinemic hypoglycemia: potential and limitations. J Vasc Interv Radiol. 2004;15(11):1251–6.

    Article  PubMed  Google Scholar 

  40. Kellogg TA, Bantle JP, Leslie DB, et al. Postgastric bypass hyperinsulinemic hypoglycemia syndrome: characterization and response to a modified diet. Surg Obes Relat Dis. 2008;4(4):492–9.

    Article  PubMed  Google Scholar 

  41. Tack J, Arts J, Caenepeel P, et al. Pathophysiology, diagnosis and management of postoperative dumping syndrome. Nat Rev Gastroenterol Hepatol. 2009;6(10):583–90.

    Article  PubMed  Google Scholar 

  42. Mordes JP, Alonso LC. Evaluation, medical therapy, and course of adult persistent hyperinsulinemic hypoglycemia after roux-en-Y gastric bypass surgery: a case series. Endocr Pract. 2015;21(3):237–46. Presents cases series of six patients with post-Roux-en-Y gastric bypass hypoglycemia and describes, in detail, their response to medical therapy and subsequent course.

    Article  PubMed  Google Scholar 

  43. Ceppa EP, Ceppa DP, Omotosho PA, et al. Algorithm to diagnose etiology of hypoglycemia after Roux-en-Y gastric bypass for morbid obesity: case series and review of the literature. Surg Obes Relat Dis. 2012;8(5):641–7.

    Article  PubMed  Google Scholar 

  44. Campos GM, Ziemelis M, Paparodis R, et al. Laparoscopic reversal of Roux-en-Y gastric bypass: technique and utility for treatment of endocrine complications. Surg Obes Relat Dis. 2014;10(1):36–43.

    Article  PubMed  Google Scholar 

  45. Sendino O, Fernandez-Esparrach G, Sole M, et al. Endoscopic ultrasonography-guided brushing increases cellular diagnosis of pancreatic cysts: a prospective study. Dig Liver Dis. 2010;42(12):877–81.

    Article  PubMed  Google Scholar 

  46. Mala T. Postprandial hyperinsulinemic hypoglycemia after gastric bypass surgical treatment. Surg Obes Relat Dis. 2014;10(6):1220–5.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of Endocrinology, Diabetes, and Metabolism, University of Pittsburgh Medical Center (UPMC), 200 Lothrop Avenue, Pittsburgh, PA, 15225, USA

    Chevon M. Rariy, David Rometo & Mary Korytkowski

  2. University of Pittsburgh School of Medicine, 200 Lothrop Avenue, Pittsburgh, PA, 15225, USA

    Chevon M. Rariy, David Rometo & Mary Korytkowski

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  1. Chevon M. Rariy
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  2. David Rometo
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Correspondence to Mary Korytkowski.

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Chevon M. Rariy, David Rometo, and Mary Korytkowski declare that they have no conflict of interest.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical Collection on Hospital Management of Diabetes

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Rariy, C.M., Rometo, D. & Korytkowski, M. Post–Gastric Bypass Hypoglycemia. Curr Diab Rep 16, 19 (2016). https://doi.org/10.1007/s11892-015-0711-5

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  • DOI: https://doi.org/10.1007/s11892-015-0711-5

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