A 51-year-old female with a past medical history of Roux-en-Y gastric bypass with multiple revisions and gastrectomy secondary to multiple gastric fistulae, obesity, asthma, and hypertension was admitted to a university medical center for multiple episodes of hypoglycemic symptoms postgastric bypass revision. During these episodes of hypoglycemia, the patient showed abrupt symptoms of palpitations, confusion, weakness, diaphoresis, shaking, trembling, tingling and numbness in her extremities, and temporary paralysis. The laboratory data on admission revealed a glucose level of 35
mg/dL. She stated that the neuroglycopenic symptoms would occur 4-5 times per week, since the gastric bypass revision was completed 3 years ago, however, did not seek medical attention. Her hypoglycemic symptoms would occur 3-4 hours after consumption of a meal, and during these neuroglycopenic episodes, she would check her blood sugar and the levels ranged between 10–25
mg/dL. The symptoms would be relieved by carbohydrate dense foods. During the admission, patient was kept n.p.o except for p.o. fluids. Blood sugar finger sticks were checked hourly, and the plan was to draw proinsulin, insulin, C-peptide, cortisol, and beta-hydroxybutyrate levels once her blood sugar decreased to less than 55
mg/dL with symptoms or less than 45
mg/dL without symptoms. On the third day of fasting, the patient had an episode of neuroglycopenia with a blood sugar of 32
mg/dL. Laboratory findings revealed a proinsulin level of 17, insulin 3.3, C-peptide 759, cortisol 8.2, and beta-hydroxybutyrate level 0.1. Endocrine examinations to exclude other causes of hypoglycemia, such as hypopituitarism and adrenal insufficiency, were within the normal range. With the history of Roux-en-Y gastric bypass, hypoglycemia and the previously described symptoms were thought to be consistent with insulin-producing lesions including an insulinoma; however, imaging studies failed to detect evidence of pancreatic masses or insulinoma. Patient underwent an abdominal CT as well as an OctreoScan study. Although imaging studies showed no mass, the patient was offered the Whipple procedure as a possible treatment; however, the patient declined. The neuroglycopenic symptoms described previously were resolved, and the patient was discharged home with a diagnosis of postprandial hypoglycemia.
The patient did not experience any episodes of hypoglycemia for the next three years after her initial presentation and discharge until she experienced an episode of altered mental status in the early morning and was brought to a local community hospital by family members. While in the emergency department (ED), the patient stated that she awoke spontaneously, found herself lying on the floor, and does not recall how she arrived there. While lying on the floor of her bedroom, she was unable to move any of her extremities for approximately twenty minutes. She stated that she experienced the same neuroglycopenic symptoms that were described previously 3 years prior. The urine toxicology screen in the ED showed no evidence of alcohol or drug abuse. Laboratory findings revealed a low fasting blood sugar of 72
mg/dL. The neuroglycopenic symptoms were relieved after ingestion of juice. Patient was discharged home with a diagnosis of hypoglycemia with no discharge medications or followup scheduled.
Patient continued to have neuroglycopenic episodes and; therefore, presented to her primary care physician, since no etiology of these episodes had been found. After meeting with the primary care physician, patient underwent another abdominal CT scan that once again showed no evidence of pancreatic masses or insulinomas. Patient was placed on acarbose 25
mg twice a day by mouth and advised to take it with meals. A cardiology, neurology, and endocrinology evaluations were sought to find the source of the syncopal episodes. Patient underwent a transthoracic echocardiogram (TTE), which revealed an estimated EF of 60%, no aortic stenosis, no cardiomyopathies, and pulmonary artery systolic pressure to be less than 30
mmHg. Electrocardiogram was normal. Cardiac causes of syncope were ruled out. Electroencephalography was normal, and no neurologic source was found to cause her syncope.
Due to the patient's history of gastric bypass, NIPHS was high on the differential, and acarbose was increased from 50
mg twice to three times a day. The patient went symptom free from the time of the first visit to the follow-up appointment 3 months later. At the second visit, a continual glucose monitor was placed underneath the skin in her abdomen. Blood sugar measurements were taken every five minutes for 5 days. During these 5 days of recording, the patient kept a journal and recorded the times of her meals and acarbose administration. Morning readings averaged 35
mg/dL, and afternoon readings averaged 40
mg/dL. After examining the blood sugar measurements over the five-day period, it was recommended that she has to increase the dose of acarbose to 150
mg three times a day by mouth and to refrain from foods that are high in carbohydrates and sugar. She is currently very compliant with her medications and her diet and has continued to be symptom free for 1 year.