Endocrine Abstracts

Introduction: Postprandial hypoglucaemia with hyperinsulinism after laparoscopic gastric bypass is an uncommon complication with an estimated prevalence of 0.2%. Its treatment includes acarbose, diazoxide, somatostatin and GLP-1 analogues or calcium channel blockers in case a strict diet does not work.

Case report: A 42-year-old woman with history of gastric bypass in 2005 due to severe obesity (preoperative weight 150 kg) attended our clinic 3 years after surgery reporting hypoglycaemic episodes occasionally accompanied by unconsciousness, occurring 3 h after food intake. The episodes resolved after sugar intake. ACTH stimulation test ruled out adrenal insufficiency. A 72-h fasting test was done with no pathological findings. A glucose tolerance test was also performed showing hypoglycaemia and hyperinsulinism. A CT scan of the abdomen did not find pancreatic nodules. Fractionated diet was started, followed by treatment with acarbose. Both measures were ineffective. Lanreotide treatment was subsequently administered with intolerance and no improvement. Diazoxide was titrated achieving only a partial response and the patient was referred to surgery for corporocaudal pancreatectomy in 2013. Pathological examination found diffuse nesidioblastosis. After the surgery, no hypoglycaemic episodes were observed. Moreover, the patient developed diabetes requiring treatment with insulin. One year after pancreatectomy the patient had a relapse of hypoglycaemia episodes even after insulin withdrawal. An overload test with mixed meal showed hyperinsulinaemic hypoglycaemia. Liraglutide 0.6 mg/24 h was prescribed but we had to stop it because of side effects. The patient was referred to a second surgery for total pancreatectomy.

Conclusions: There is no treatment of choice for patients with nesidioblastosis. Medical treatment, including somatostatin and GLP-1 analogues, should be tried before surgery. When medical treatment fails, subtotal pancreatectomy is a good option to control hypoglucaemia and preserve pancreatic function. When hypoglycaemia persists, total pancreatectomy should be considered.