Endocrine Abstracts

Postprandial Hyperinsulinaemic Hypoglycaemia reportedly occurs in 0.1 to 0.3% of patients after Roux-en-Y Bypass procedures. In our Bariatric Surgery Service we seem to be seeing this complication more frequently. Most patients can be managed in a step-wise approach, but we have a few patients who appear refractory to conventional treatment. This case illustrates one such patient. Mrs P was referred to the Weight Management service in 2011, aged 45. She weighed 108 kg, with a BMI of 40 kg/m². She had type 2 diabetes, but no other past medical history and was working in a high profile job. A Roux-en-Y bypass was performed in November 2011, with no immediate complications. She successfully lost 25% of her body weight and by April 2012 weighed 79.2 kg. Towards the end of 2015 she was re-referred with symptoms of severe fatigue, poor concentration and mood changes. She had been signed of sick by occupational health. Investigations revealed no evidence of anaemia, or vitamin deficiency and a normal cortisol response to synacthen. Treatment with a course of thiamine and Pabrinex initially improved her symptoms but they then returned. Despite denying symptoms of dumping syndrome and hypoglycemia, a decision was made to proceed with Continuous Glucose Monitoring (CGM). This revealed hypoglycaemia 2–3 hours after meals. A clinical diagnosis of hyperinsulinaemic hypoglycaemia was made and she was referred to the dietitian. Changing her diet initially improved her symptoms but they then returned. Acarbose and diltiazem were next tried without success. Liraglutide, followed by octreotide, were then trialled, which resulted in only temporary improvement. Due to the persistence of her hypoglycaemia a CT-pancreas, 72 h fast & octreotide scan were performed ruling out an insulinoma. In early 2017 she successfully returned to work on Prednisolone, quick-acting insulin with meals, Octreotide and with a CGM funded through exceptional funding. In the last 3 months however, her hypos have returned and she has had to take early retirement. Her most recent CGM download shows she spends 19% of her time with a blood glucose <4 mmol/l and 5% <3 mmol/l. She is adamant that she does not want further surgery. Various options have now been discussed including trialing a dual insulin and glucagon pump. This case illustrates the devastating effects that Hyperinsulinaemic Hypoglycaemia can have on someone’s quality of life. More evidence is needed to support new treatments to reduce hypoglycaemia in this cohort of patients who appear refractory to conventional therapy.