Hyperinsulinemic Hypoglycemia after Bariatric Surgery: Challenges with a Patient with an Associated Eating Disorder

Presentation Number: THR-547
Date of Presentation: March 5th, 2015

Karyne Lima Vinales*1 and Allison Peckumn2
1Banner Good Samaritan Medical Center, Phoenix, AZ, 2Banner Good Samaritan Medical Center, Goodyear, AZ

Abstract

Background: Hyperinsulinemic hypoglycemia (HIH) after bariatric surgery is a rare entity. Its treatment is challenging, and no cases with associated eating disorders have been described.

Clinical case: 33 year old nurse with a history of Roux-en-Y gastric bypass surgery in 2003 was transferred to the hospital from an inpatient treatment center where she was being treated for bulimia nervosa for severe hypoglycemic episodes. These episodes started in 2009, and even resulted in an MVA in 2012. She had classic symptoms of hypoglycemia. Her eating disorder, diagnosed in 2006, started with restriction and later progressed to purging after meals. Patient also has bipolar disorder and panic attacks. At the treatment center, she was initially placed on enteral feedings, as she refused to eat, and there was no reported hypoglycemia. Once on an oral diet, she had frequent post-prandial hypoglycemia. Patient was on multiple psychiatric medications; none were felt to be related. Patient was treated with IV dextrose, and was later weaned off. As soon she was placed on a regular diet, she had a blood sugar of 47 mg/dL with concomitant insulin level of 11 uIU/mL, C-peptide 4.2 ng/mL, Beta-Hydroxybutyrate 0.8 mg/dL, pro-insulin 27.8 pmol/L. Hypoglycemia responded to glucagon.

Anti-insulin antibody, sulfonylurea and glinide levels were undetectable. CT scan of abdomen was negative for visible pancreatic lesion. Patient would not adhere to a low carbohydrate diet as she was afraid she would gain weight.  She failed treatment with acarbose up to 100 mg TID. She also failed to respond to octreotide up to 50 mcg TID, plus she was very resistant to using subcutaneous medications chronically. She responded partially to diazoxide. Because of her profession and her mental health history, the question of factitious hypoglycemia was raised, but was ruled out after lab results were received and patient was continuously supervised.  The patient underwent endoscopic ultrasound and was found to have a suspicious 1cm pancreatic lesion, with negative fine needle aspiration for pathologic cells. On selective arterial calcium stimulation, there was an overall three-fold increase in insulin, but no difference between arteries.  The patient’s most likely diagnosis is nesidioblastosis. Near total pancreatectomy was discussed. She was not felt to be a good surgical candidate while she was actively struggling with bulimia.  She returned to inpatient treatment for her eating disorder with persistent sporadic mild post-prandial hypoglycemic episodes.

Conclusion: This is the first case described of hyperinsulinemic hypoglycemia after gastric bypass surgery case complicated by an eating disorder, and it illustrates the difficulty of treatment of not only HIH, but also addresses ethical dilemmas encountered in a patient with a psychiatric condition.

 

Nothing to Disclose: KLV, AP