Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
Current Diabetes Reports
Published in: Current Diabetes Reports 2/2016

01-02-2016 | Hospital Management of Diabetes (GE Umpierrez, Section Editor)

Post–Gastric Bypass Hypoglycemia

Authors: Chevon M. Rariy, David Rometo, Mary Korytkowski

Published in: Current Diabetes Reports | Issue 2/2016

Login to get access

Abstract

Obesity is a major public health problem worldwide. Obesity-related illnesses, such as coronary heart disease, type 2 diabetes, hypertension, dyslipidemia, stroke, sleep apnea, and several forms of cancer (endometrial, breast, and colon), contribute to a significant number of deaths in the USA. Bariatric surgery, including the Roux-en-Y gastric bypass (RYGB) procedure, has demonstrated significant improvements in obesity and obesity-related co-morbidities and is becoming more popular as the number of obese individuals rises. Despite the reported benefits of bariatric surgery, there are potential complications that physicians need to be aware of as the number of patients undergoing these procedures continues to increase. One challenging and potentially life-threatening complication that to date is not well understood is post-RYGB surgery hypoglycemia (PGBH). In this review, we will present the definition, historical perspective, diagnostic approach, currently available treatment options, and anecdotal assessment and treatment algorithm for this disorder.
Literature
1.
Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9945):766–81.PubMedCentralCrossRefPubMed
2.
Ogden CL, Carroll MD, Kit BK, et al. Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA. 2014;311(8):806–14.CrossRefPubMed
3.
Finkelstein EA, Trogdon JG, Cohen JW, et al. Annual medical spending attributable to obesity: payer-and service-specific estimates. Health Aff (Millwood). 2009;28(5):w822–31.CrossRef
4.
5.
Flegal KM, Graubard BI, Williamson DF, et al. Excess deaths associated with underweight, overweight, and obesity. JAMA. 2005;293(15):1861–7.CrossRefPubMed
6.•
Sjostrom L. Review of the key results from the Swedish Obese Subjects (SOS) trial - a prospective controlled intervention study of bariatric surgery. J Intern Med. 2013;273(3):219–34. One of the first large scale studies that describe the prevalence rate of PGBH, though it is still likely that the rate is low in part due to inadequate recognition.CrossRefPubMed
7.
Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012;366(17):1567–76.PubMedCentralCrossRefPubMed
8.
Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med. 2012;366(17):1577–85.CrossRefPubMed
9.
Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357(8):753–61.CrossRefPubMed
10.
Cui Y, Elahi D, Andersen DK. Advances in the etiology and management of hyperinsulinemic hypoglycemia after Roux-en-Y gastric bypass. J Gastrointest Surg. 2011;15(10):1879–88.CrossRefPubMed
11.
12.
Patti ME, McMahon G, Mun EC, et al. Severe hypoglycaemia post-gastric bypass requiring partial pancreatectomy: evidence for inappropriate insulin secretion and pancreatic islet hyperplasia. Diabetologia. 2005;48(11):2236–40.CrossRefPubMed
13.
Service GJ, Thompson GB, Service FJ, et al. Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric-bypass surgery. N Engl J Med. 2005;353(3):249–54.CrossRefPubMed
14.
Marsk R, Jonas E, Rasmussen F, et al. Nationwide cohort study of post-gastric bypass hypoglycaemia including 5,040 patients undergoing surgery for obesity in 1986–2006 in Sweden. Diabetologia. 2010;53(11):2307–11.CrossRefPubMed
15.
Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357(8):741–52.CrossRefPubMed
16.••
Lee CJ, Clark JM, Schweitzer M, et al. Prevalence of and risk factors for hypoglycemic symptoms after gastric bypass and sleeve gastrectomy. Obesity (Silver Spring). 2015;23(5):1079–84. This study is one of the first larger studies to report prevalence and associated risk factors for PGBH with an emphasis on recognition of symptoms of hypoglycemia.CrossRef
17.
Vella A, Service FJ. Incretin hypersecretion in post-gastric bypass hypoglycemia--primary problem or red herring? J Clin Endocrinol Metab. 2007;92(12):4563–5.CrossRefPubMed
18.
Won JG, Tseng HS, Yang AH, et al. Clinical features and morphological characterization of 10 patients with noninsulinoma pancreatogenous hypoglycaemia syndrome (NIPHS). Clin Endocrinol (Oxf). 2006;65(5):566–78.CrossRef
19.
Service FJ, Natt N, Thompson GB, et al. Noninsulinoma pancreatogenous hypoglycemia: a novel syndrome of hyperinsulinemic hypoglycemia in adults independent of mutations in Kir6.2 and SUR1 genes. J Clin Endocrinol Metab. 1999;84(5):1582–9.PubMed
20.
Service FJ. Recurrent hyperinsulinemic hypoglycemia caused by an insulin-secreting insulinoma. Nat Clin Pract Endocrinol Metab. 2006;2(8):467–70. quiz following 470.CrossRefPubMed
21.
Placzkowski KA, Vella A, Thompson GB, et al. Secular trends in the presentation and management of functioning insulinoma at the Mayo Clinic, 1987–2007. J Clin Endocrinol Metab. 2009;94(4):1069–73.CrossRefPubMed
22.
Shealy RM, Simpson Jr WM, Lee FW, et al. The gaping hole: physicians are missing from the front line of disaster preparedness training. J S C Med Assoc. 2006;102(1):11–3.PubMed
23.
Cryer PE, Axelrod L, Grossman AB, et al. Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2009;94(3):709–28.CrossRefPubMed
24.
Melmed S, Williams RH, 1897. Williams textbook of endocrinology. 12th ed. Philadelphia: Elsevier/Saunders; 2011. p. 1897. xviii.
25.
26.
27.
Meier JJ, Butler AE, Galasso R, et al. Hyperinsulinemic hypoglycemia after gastric bypass surgery is not accompanied by islet hyperplasia or increased beta-cell turnover. Diabetes Care. 2006;29(7):1554–9.CrossRefPubMed
28.
Goldfine AB, Mun EC, Devine E, et al. Patients with neuroglycopenia after gastric bypass surgery have exaggerated incretin and insulin secretory responses to a mixed meal. J Clin Endocrinol Metab. 2007;92(12):4678–85.CrossRefPubMed
29.
McLaughlin T, Peck M, Holst J, et al. Reversible hyperinsulinemic hypoglycemia after gastric bypass: a consequence of altered nutrient delivery. J Clin Endocrinol Metab. 2010;95(4):1851–5.CrossRefPubMed
30.
Cummings DE. Gastric bypass and nesidioblastosis--too much of a good thing for islets? N Engl J Med. 2005;353(3):300–2.CrossRefPubMed
31.
Toft-Nielsen M, Madsbad S, Holst JJ. Exaggerated secretion of glucagon-like peptide-1 (GLP-1) could cause reactive hypoglycaemia. Diabetologia. 1998;41(10):1180–6.CrossRefPubMed
32.
Salehi M, Prigeon RL, D’Alessio DA. Gastric bypass surgery enhances glucagon-like peptide 1-stimulated postprandial insulin secretion in humans. Diabetes. 2011;60(9):2308–14.PubMedCentralCrossRefPubMed
33.••
Salehi M, Gastaldelli A, D’Alessio DA. Blockade of glucagon-like peptide 1 receptor corrects postprandial hypoglycemia after gastric bypass. Gastroenterology. 2014;146(3):669–680 e2. Elegant trial in which a GLP-1 receptor antagonist was used to show that PGBH was corrected after administration. Thus, both providing support to the hypothesis that PGBH is at least in part mediated by excess GLP-1 and also serve as a possible treatment strategy for these patients.PubMedCentralCrossRefPubMed
34.
Liou AP, Paziuk M, Jr Luevano JM, et al. Conserved shifts in the gut microbiota due to gastric bypass reduce host weight and adiposity. Sci Transl Med. 2013;5(178):178ra41.PubMedCentralCrossRefPubMed
35.
Patti ME, Houten SM, Bianco AC, et al. Serum bile acids are higher in humans with prior gastric bypass: potential contribution to improved glucose and lipid metabolism. Obesity (Silver Spring). 2009;17(9):1671–7.CrossRef
36.
Cummings DE, Weigle DS, Frayo RS, et al. Plasma ghrelin levels after diet-induced weight loss or gastric bypass surgery. N Engl J Med. 2002;346(21):1623–30.CrossRefPubMed
37.
38.•
Kefurt R, Langer FB, Schindler K, et al. Hypoglycemia after Roux-En-Y gastric bypass: detection rates of continuous glucose monitoring (CGM) versus mixed meal test. Surg Obes Relat Dis. 2015;11(3):564–9. There are challenges to mixed meal testing in the diagnosis of PGBH. This study provides data to support the use of continuous glucose monitoring under real-life conditions to aid in the diagnosis and evaluation of therapy for PGBH.CrossRefPubMed
39.
Wiesli P, Brandle M, Schmid C, et al. Selective arterial calcium stimulation and hepatic venous sampling in the evaluation of hyperinsulinemic hypoglycemia: potential and limitations. J Vasc Interv Radiol. 2004;15(11):1251–6.CrossRefPubMed
40.
Kellogg TA, Bantle JP, Leslie DB, et al. Postgastric bypass hyperinsulinemic hypoglycemia syndrome: characterization and response to a modified diet. Surg Obes Relat Dis. 2008;4(4):492–9.CrossRefPubMed
41.
Tack J, Arts J, Caenepeel P, et al. Pathophysiology, diagnosis and management of postoperative dumping syndrome. Nat Rev Gastroenterol Hepatol. 2009;6(10):583–90.CrossRefPubMed
42.•
Mordes JP, Alonso LC. Evaluation, medical therapy, and course of adult persistent hyperinsulinemic hypoglycemia after roux-en-Y gastric bypass surgery: a case series. Endocr Pract. 2015;21(3):237–46. Presents cases series of six patients with post-Roux-en-Y gastric bypass hypoglycemia and describes, in detail, their response to medical therapy and subsequent course.CrossRefPubMed
43.
Ceppa EP, Ceppa DP, Omotosho PA, et al. Algorithm to diagnose etiology of hypoglycemia after Roux-en-Y gastric bypass for morbid obesity: case series and review of the literature. Surg Obes Relat Dis. 2012;8(5):641–7.CrossRefPubMed
44.
Campos GM, Ziemelis M, Paparodis R, et al. Laparoscopic reversal of Roux-en-Y gastric bypass: technique and utility for treatment of endocrine complications. Surg Obes Relat Dis. 2014;10(1):36–43.CrossRefPubMed
45.
Sendino O, Fernandez-Esparrach G, Sole M, et al. Endoscopic ultrasonography-guided brushing increases cellular diagnosis of pancreatic cysts: a prospective study. Dig Liver Dis. 2010;42(12):877–81.CrossRefPubMed
46.
Mala T. Postprandial hyperinsulinemic hypoglycemia after gastric bypass surgical treatment. Surg Obes Relat Dis. 2014;10(6):1220–5.CrossRefPubMed
Metadata
Title
Post–Gastric Bypass Hypoglycemia
Authors
Chevon M. Rariy
David Rometo
Mary Korytkowski
Publication date
01-02-2016
Publisher
Springer US
Published in
Current Diabetes Reports / Issue 2/2016
Print ISSN: 1534-4827
Electronic ISSN: 1539-0829
DOI
https://doi.org/10.1007/s11892-015-0711-5

Other articles of this Issue 2/2016

Current Diabetes Reports 2/2016 Go to the issue

Pathogenesis of Type 2 Diabetes and Insulin Resistance (RM Watanabe, Section Editor)

Genetics of Gestational Diabetes Mellitus and Maternal Metabolism

Other Forms of Diabetes (JJ Nolan, Section Editor)

Diabetes and Schizophrenia

Microvascular Complications—Nephropathy (AP Maxwell, Section Editor)

Diabetic Nephropathy in Women With Preexisting Diabetes: From Pregnancy Planning to Breastfeeding

Microvascular Complications—Nephropathy (AP Maxwell, Section Editor)

An Update on the Use of Animal Models in Diabetic Nephropathy Research

Hospital Management of Diabetes (GE Umpierrez, Section Editor)

Hyperglycemia and Diabetes Mellitus Following Organ Transplantation

Diabetes and Pregnancy (CJ Homko, Section Editor)

Identifying Key Intervention Opportunities During a Pregnancy Complicated by Diabetes: a Review of Acute Complications of Diabetes During Pregnancy
Live Webinar | 27-06-2024 | 18:00 (CEST)

Keynote webinar | Spotlight on medication adherence

Reserve your place

Live: Thursday 27th June 2024, 18:00-19:30 (CEST)

WHO estimates that half of all patients worldwide are non-adherent to their prescribed medication. The consequences of poor adherence can be catastrophic, on both the individual and population level.

Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.

Prof. Kevin Dolgin
Prof. Florian Limbourg
Prof. Anoop Chauhan
Developed by: Springer Medicine
Obesity Clinical Trial Summary

At a glance: The STEP trials

Read more

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.

Developed by: Springer Medicine

Highlights from the ACC 2024 Congress

Year in Review: Pediatric cardiology

Pediatric Cardiology Video

Watch Dr. Anne Marie Valente present the last year's highlights in pediatric and congenital heart disease in the official ACC.24 Year in Review session.

Year in Review: Pulmonary vascular disease

Cardiopulmonary Comorbidity Video

The last year's highlights in pulmonary vascular disease are presented by Dr. Jane Leopold in this official video from ACC.24.

Year in Review: Valvular heart disease

Valvular Heart Disease Video

Watch Prof. William Zoghbi present the last year's highlights in valvular heart disease from the official ACC.24 Year in Review session.

Year in Review: Heart failure and cardiomyopathies

Heart Failure Video

Watch this official video from ACC.24. Dr. Biykem Bozkurt discusses last year's major advances in heart failure and cardiomyopathies.

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Heart Failure Video

Watch this official video from ACC.24. Dr. Biykem Bozkurt discusses last year's major advances in heart failure and cardiomyopathies.

Watch now

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

16-04-2024 Type 2 Diabetes News

Incentivised to exercise

11-04-2024 Lifestyle Modifications News

New intervention for STEMI-related cardiogenic shock

10-04-2024 Myocardial Infarction News

» View more highlights on the ACC 2024 congress hub page

Image Credits