Successful Management of Refractory Noninsulinoma Pancreatogenous Hypoglycemia Syndrome With Gastric Bypass Reversal: A Case Report: 1037

Abstract

Introduction: Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric surgery in the United States. One rare late postoperative complication is postprandial neuroglycopenia due to noninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS). Prior reports of surgical management of NIPHS include gradient-guided partial or total pancreatectomy. We report a case of gastric bypass reversal for the successful treatment of refractory NIPHS. Case Report: A 58-year-old white male with a history of ischemic cardiomyopathy, hypertension, diabetes mellitus, and RYGB 1 year prior for morbid obesity, presented to our hospital for the evaluation of multiple generalized seizures over the prior 3 months. Episodes occurred several hours after eating with blood glucose (BG) ranging from 30-80 mg/dL, without recent oral hypoglycemic or insulin use. Laboratory testing including insulin antibodies, oral hypoglycemic agents, pituitary axis hormone levels, cortisol stimulation, and dexamethasone suppression tests were unrevealing. Computed tomography (CT) scan of the abdomen was unremarkable. A 72-hour fasting test was without hypoglycemia. Induced hypoglycemia with 75% carbohydrate meal intake showed BG of 36 mg/dL 3 hours later, with inappropriately elevated C peptide, pro-insulin and insulin levels; consistent with endogenous hyperinsulinemic hypoglycemia (EHH). Subsequent selective arterial calcium stimulation testing (SACST) revealed a 2, 3, and 9-fold increase in insulin level…