Category: Diabetes/Prediabetes/Hypoglycemia

Monitor: 34

34 - RARE CASE OF POST GASTRIC BYPASS NESIDIOBLASTOSIS RESISTANT TO MEDICAL TREATMENT

Friday, Apr 26
12:30 PM – 1:00 PM

Objective : To describe a rare case presentation of post Roux-en-Y gastric bypass hypoglycemia, presumably nesidioblastosis


Methods : A case report with medical history, diagnostic and treatment course is presented with discussion


Results : A 31 year-old female with previous history of type 2 diabetes mellitus requiring insulin which resolved after Roux-en-Y gastric bypass surgery 8 years ago presented with recurrent hypoglycemia during and after a pregnancy. Her 3rd pregnancy was complicated with excessive weight gain and gestational diabetes for which she required insulin. However her dose was lowered during her pregnancy and was stopped due to hypoglycemic episodes. She was subsequently hospitalized multiple times with  episodes of severe hypoglycemia, both post-prandial and nocturnal. Although her 72-hour fasting study result was positive for hyperinsulinemic hypoglycemia, various radiologic studies including magnetic resonance imaging, endoscopic ultrasound, selective calcium stimulation test and gallium-68 DOTATATE positron emission tomography failed to localize any suspicious lesion except for an incidental hepatic hemangioma. Over several months, she went through vigorous medical monitoring and treatment of hypoglycemia including continuous glucose monitor, dietary modification, acarbose, diazoxide, corticosteroid and octreotide injection without definitive success. She continues to have treatment-resistant hypoglycemia and is currently awaiting for surgical evaluation for further diagnostic and therapeutic intervention.


Discussion : Nesidioblastosis in adults is a rare disease in which pancreatic beta cell hyperplasia results in  hyperinsulinemic hypoglycemia. The hypoglycemia during overnight fast in our patient is unusual.  Diagnosis can often be perplexing and therapeutic options are limited. There has been increasing number of reports of nesidioblastosis after Roux-en-Y gastric bypass without clear understanding, often requiring invasive surgical procedures such as reversal of gastric bypass or subtotal pancreatectomy. A few reports have proposed its underlying involvement of glucagon-like peptide-1 pathway, but the exact mechanism is still unknown.


Conclusion : We have presented a rare case of presumed nesidioblastosis in a post-gastric-bypass patient with hypoglycemia. As the obesity epidemic exacerbates, many people are opting for bariatric surgery. Identification of this rare adverse effect is critical, and treatment options should be investigated further.

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Esra Kalkan

Fellow
Icahn School fo Medicine at Mount Sinai Beth Israel

Clinical Fellow

Tai Ho Shin

Fellow
Icahn School fo Medicine at Mount Sinai Beth Israel
New York

Clinical Fellow

Robert Bernstein

Associate Professor
Mt. Sinai St. Luke's Hospital

Associate Professor

Hongfa Zhu

Francisco Diaz