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Reactive hypoglycemia following gastrectomy is a consequence of hyperinsulinism resulting from rapid gastric emptying of ingested food Symptoms result from adrenergic hyperactivity in response to the hypoglycemia Treatment consists of more frequent feedings with smaller portions of less rapidly assimilated carbohydrate combined with more slowly absorbed fat and protein Cases of hypoglycemia have been reported in patients who have undergone Roux-en-Y gastric bypass surgery for the treatment of obesity The hypoglycemia occurs after meals and can be severe Some of these patients are found to have islet cell hyperplasia

PERSISTENT ISLET HYPERPLASIA (NONINSULINOMA PANCREATOGENOUS HYPOGLYCEMIA SYNDROME)

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In a very small number of patients with organic hyperinsulinism, islet hyperplasia rather than an adenoma is present These patients typically have documented hyperinsulinemic hypoglycemia after meals but not with fasting up to 72 hours The patients have a positive response to calcium-stimulated angiography A gradient-guided partial pancreatectomy leads to clinical remission, and the pathology of the pancreas shows evidence of islet hyperplasia and nesidioblastosis These patients do not have mutations in the Kir 62 and SUR1 genes, which has been reported in children with familial hyperinsulinemic hypoglycemia

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This syndrome is classified as functional when no postsurgical explanation exists for the presence of early alimentary type reactive hypoglycemia It is most often associated with chronic fatigue, anxiety, irritability, weakness, poor concentration, decreased libido, headaches, hunger after meals, and tremulousness However, most patients with these symptoms do not have hypoglycemia after a mixed meal (See Chronic Fatigue Syndrome in 2) Indiscriminate use and overinterpretation of glucose tolerance tests have led to an unfortunate tendency to overdiag-

These rare causes of hypoglycemia include mesenchymal tumors such as retroperitoneal sarcomas, hepatocellular car-

nose functional hypoglycemia As many as one-third or more of normal subjects have blood glucose levels as low as 40 50 mg/dL with or without symptoms during a 4-hour glucose tolerance test Accordingly, to increase diagnostic reliability, hypoglycemia should preferably be documented during a spontaneous symptomatic episode accompanying routine daily activity, with clinical improvement following feeding Oral glucose tolerance tests are overly sensitive and mixed meals are relatively insensitive in detecting postprandial reactive hypoglycemia It has been shown that a high-carbohydrate breakfast has proved useful in differentiating persons with postprandial reactive hypoglycemia from normal controls The test resulted in reactive hypoglycemia to levels below 59 mg/dL in 47% of 38 subjects, in contrast to only 22% of the 43 controls This test was found to be much more sensitive than a standard mixed meal, which was also given to these two groups In patients with documented postprandial hypoglycemia on a functional basis, there is no harm and occasional benefit in reducing the proportion of carbohydrate in the diet while increasing the frequency and reducing the size of meals Support and mild sedation should be the mainstays of therapy, with dietary manipulation only an adjunct

When sugar-containing soft drinks are used as mixers to dilute alcohol in beverages (gin and tonic, rum and cola), there seems to be a greater insulin release than when the soft drink alone is ingested and a tendency for more of a late hypoglycemic overswing to occur 3 4 hours later Prevention would consist of avoiding sugar mixers while ingesting alcohol and ensuring supplementary food intake to provide sustained absorption

van de Wiel A Diabetes mellitus and alcohol Diabetes Metab Res Rev 2004 Jul Aug;20(4):263 7 [PMID: 15250029]

Factitious hypoglycemia may be difficult to document A suspicion of self-induced hypoglycemia is supported when the patient is associated with the health professions or has access to insulin or sulfonylurea drugs taken by a diabetic member of the family The triad of hypoglycemia, high immunoreactive insulin, and suppressed plasma C peptide immunoreactivity is pathognomonic of exogenous insulin administration Demonstration of circulating insulin antibodies supports this diagnosis in suspected cases When sulfonylureas are suspected as a cause of factitious hypoglycemia, a plasma level of these drugs to detect their presence may be required to distinguish laboratory findings from those of insulinoma Unfortunately, the newer sulfonylurea, glimepiride, and other insulinotropic hypoglycemic drugs like repaglinide and nateglinide are not detected in the standard assays for sulfonylureas

Charlton R et al Munchausen's syndrome manifesting as factitious hypoglycaemia Diabetologia 2001 Jun;44(6):784 5 [PMID: 11440375] Hirshberg B et al Repaglinide-induced factitious hypoglycemia J Clin Endocrinol Metab 2001 Feb;86(2):475 7 [PMID: 11157993] Trenque T et al Prevalence of factitious hypoglycaemia associated with sulphonylurea drugs in France in the year 2000 Br J Clin Pharmacol 2002 Nov;54(5):548 [PMID: 12445037]

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