How Low Can You Go? Post Op Hypoglycemia part 2

From EndlessGroove.com

Now that you suspect a post- Bypass patient is presenting with symptoms of, or issues related to hypoglycemia, here's the work up, treatment modalities, and the attendant potential long term implications.

First off, we want to ascertain whether the hypoglycemia is physiologic (related to behavior and / or dumping syndrome), or from an associated hyperinsulinemic state (which has been described after Bypass).

The vast majority are the former, related to dietary indiscretion of repeated ingestion of simple CHO, not eating enough protein at a meal, and/or not eating in a regular fashion / skipping meals with a prolonged fasting state.

Lab workup should include a fasting glucose, C-Peptide, and fasting insulin level, with perhaps a glycohemoglobin.  Again, an elevated insulin level may indicate the need for further testing, imaging studies, and likely and Endocrine eval for the possibility of Pancreatic Nesidioblastosis.

Blood glucose sampling at the time of the patient's symptoms may help confirm the hypoglycemia, as well as the history of an efficient response to a small amount of simple CHO will also be helpful.

Getting back to proper Bariatric behavior in the way of 3 (or more) meals per day high in protein and low in CHO (especially simple CHO), and avoiding prolonged periods of 'fasting' in between meals has been advocated. Avoiding eating and drinking together slows down the entry of chyme into the small intestine.  Our Dietitian helps the patient sort this out, and reinforce the proper habits.

Having the patient check their BGs prior to driving, exercise, at HS, etc. may help them to have a better sense of control and correlate symptoms with triggers and situations where lowered BG (or syncope) may pose a significant issue.

Should the episodes still continue despite behavioral change, Acarbose can be prescribed.  At 50-100 mg TID, preferrably 10 mins prior to a meal, case reports have shown that the medicine-induced delay in CHO absorption helps with minimizing the associated hypoglycemia as a rebound from a rapid increase in glucose associate with dumping syndrome. Other meds such as Octreotide and Calcium Channel blockers have also been mentioned as potentially helpful.

So, now that we are keeping in mind the presentation of hypoglycemia in post-op Bypass patients, we also need to mention it as a cause of weight regain after surgery.  We always stress the behavioral component as the main etiologic factor, of which there is very often sufficient evidence in the history of repeated indiscretions. However, unchecked hypoglycemia can be a possible factor.  Having a patient go through cycles of hypoglycemia with an acute desire to eat to resolve their symptoms, and have that pattern recur repetitively,  can certainly cause substantial regain of weight over time.

And again, getting back to Bariatric basics for behavior, such as eating properly, exercise, and follow up visits to be reevaluated, is paramount to getting back on track and maintaining good health and weight maintenance long term.