Endocrine Abstracts

Introduction: Patients with bariatric surgery require close monitoring because of possible metabolic complications. It has been published some cases of severe and persistent hypoglycemias resistant to diet and pharmacologic treatment being necessary a pancreatectomy. We present a case report of nesidioblastosis after gastric bypass that required subtotal pancreatectomy but despite this, hypoglycemias persisted. Before performing total pancreatectomy we placed a tube feeding in remnant stomach and hypoglycemias disappeared.

Case report: 45 years woman with morbid obesity (BMI =48) underwent gastrojejunal bypass. One year later (BMI=25.9) she began with postprandial hypoglycemia that did not improve after diet and acarbose. Basal analysis and fasting test were normal. OGGT revealed hyperinsulinism and hypoglycemia. Imaging test were normal. After oral load of three enteral nutrition products (1, rich in fast absortion carbohidrates; 2, slow absorption carbohydrate with insoluble fiber and 3, monounsaturated fatty acids rich) were observed descending degrees, respectively, of hyperinsulinism and hypoglycemia. Mesenteric arteriography with intra-arterial calcium stimulation and measurement of insulin and C peptide in hepatic vein revealed a right hypersecretion in splenic and superior mesenteric area (pancreatic body and tail) Given the persistence of hypog. partial pancreatic resection was decided. Pathologic examination revealed diffuse hyperplasia of islets supporting diagnosis of nesidioblastosis. Despite initial improvement, hypoglycemias returned so it was decided to perform a gastrostomy for enteral nutrition, while orally she only ate proteins and fats. After this, hypoglycemias disappeared.

Conclusion: The clinical significance of this case resides in the few cases reported to date with this evolution to our knowledge (only one previously published case) and the possible therapeutic implications:published literature advises complete pancreatectomy if hypoglycemia persists after partial pancreatectomy, however the performance of gastrostomy may be a much less aggressive therapeutic approach. Likewise, the persistence of hypoglycemia after subtotal pancreatectomy with subsequent resolution after gastrostomy in remnant stomach supports a major role of rapid release of food to the ileum and production of gastrointestinal peptides more than the cell hyperplasia of islets in itself as main cause of hypoglycemia.

Declaration of interest: The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.

Funding: This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.