SAT169 Sugar Crash: A Case Of Recurrent Hypoglycemia

Disclosure: C.T. Malvar: None. P. Patel: None. H. Moran: None. D. Bleich: None. Introduction: Post-prandial hypoglycemia is a rare complication following Roux-en-Y gastric bypass surgery (RYGB). Some theories suggest that post-operative beta cell expansion and altered beta cell function may lead to increased secretion of insulin, thereby causing hypoglycemia. We report a 39-year-old female with multiple episodes of recurrent post-prandial hypoglycemia following RYGB. Case Report: A 39-year-old female with a past medical history of type 2 diabetes managed with insulin, hypertension, hyperlipidemia, and obesity underwent RYGB and developed multiple episodes of fatigue, diaphoresis, palpitations, and tremulousness a year later. The patient continued to have worsening symptoms, leading to multiple hospitalizations for hypoglycemia. During her initial presentation to the emergency department, she was found to be afebrile, tachycardic with stable blood pressure. Work up revealed a glucose of 34 mg/dl (70 - 109 mg/dl), insulin of 40.1 (2.6 - 24.9 uIU/mL), C-peptide of 3.8 (1.1 - 4.4 ng/mL), potassium of 3.2 (3.5 - 4.8 meq/l), negative sulfonylurea screen, normal renal function, and a mild leukocytosis of 12.6 (4.0 - 11.0 x 10*3/µL). CT abdomen/pelvis, chest x-ray, and urinalysis were normal and did not reveal any infection. The patient denied taking any hypoglycemic agents and reported consuming high glycemic index meals. During her hospitalization, she received a bolus of dextrose followed by a continuous dextrose drip; however, she continued to experience recurrent hypoglycemic events requiring glucagon and dextrose tablets. Subsequent morning labs showed elevated insulin levels at 34.6 (2.6 - 24.9 uIU/mL) and a normal IGF-1 level. Her 8AM cortisol level was 2.3 (6.0 - 18.4 ug/dl). Due to high suspicion of adrenal insufficiency, she was started on Hydrocortisone. Pituitary MRI was negative for any adenoma. Hydrocortisone was held and a cosyntropin stimulation test established appropriate adrenal response. Hydrocortisone and dextrose tablets were discontinued. She was educated on eating low glycemic index meals to prevent future hypoglycemic episodes. She was started on acarbose as it delays carbohydrate degradation, thereby preventing reactive hypoglycemia. Conclusion: This case highlights the importance of having a thorough differential diagnosis in patients with a history of bariatric surgery and hypoglycemic episodes including adrenal insufficiency, which in this case was ruled out. RYGB increases stimulation of islet β-cells by enteral signals and enhances GLP-1 sensitivity and insulin secretion, predisposing some individuals to hypoglycemic episodes. Patients may have remission of diabetes and no longer need medications post-operatively. Dietary modification is fundamental in the management of hypogylcemia after RYGB. Pharmacotherapy is an adjunctive treatment if symptoms persist. Presentation: Saturday, June 17, 2023