How Low Can You Go? Post Op Hypoglycemia, part 1

From Endless Groove.com

Hypoglycemia is a pretty easy thing to diagnose, usually associated with a Diabetic patient that has a relative excess of insulin from treatment for their Diabetes. The mild symptoms are often either treated by the patient on their own, or perhaps first verified by finger stick and treated accordingly with simple CHOs.  The patient fairly rapidly gets better, and that is that.

How about in the setting of the absence of anti Diabetic meds, and with the surgical history of a prior Gastric Bypass?

Well, with all good things, there is not uncommonly a downside.  Here is another such case.

The metabolic benefits of Gastric Bypass so touted in this Blog do have the possibility of causing symptomatic hypoglycemia. Although relatively rare, it can occur months to years after surgery, with the associated significant and rapid weight loss.  In some patients, with hypoglycemia unawareness, it can progress to to neuroglycopenia, occasionally resulting in syncope.

What are the mechanisms, presentations, treatments, and what about the potential association with weight regain?

Possible mechanisms encouraging hypoglycemia post-Gastric Bypass:

1.  Lack of reduction of beta-cell mass from pre-weight loss pancreatic state

2.  Gut hormonal activation of new beta-cell formation in the Pancreas

3.  Increased insulin sensitivity after weight loss

4.  Inappropriate beta-cell secretion as a part of the dumping syndrome of early entry of ingested nutrients into the small intestine, and

5.  Abnormal counter-regulatory hormonal responses (Glucagon)

The above article was mainly written for the discussion of a hyperinsulinemic state discovered in an even smaller proportion of hypoglycemic Bypass patients, although the mechanisms are the same for the garden variety cases as well.  The latter is more closely linked to the dumping syndrome described above, which is typically managed with dietary manipulation and/or meds.

Most articles I reviewed described the hypoglycemia as occurring 2-3 years after successful Bypass, and most commonly 2-3 hours after an ingested meal.

The symptoms were fairly typical, with palpitations, sweating, visual changes, diaphoresis, dizziness, and mental status changes.  As described earlier, with a degree of 'unawareness', the first manifestation may be syncope.  Admittedly, there is never really a good time for syncope during one's daily activities.

In Part 2 we will review the workup, the treatments from dietary to pharmacologic, and discuss the likely association of hypoglycemia with the possibility of weight regain years after surgery.