Postprandial Hyperinsulinemic Hypoglycemia in Bariatric Surgery

Postprandial hyperinsulinemic hypoglycemia (PHH) is a complication of bariatric surgery, especially Roux-en-Y gastric bypass. The true incidence is not known as the definition of PHH is not clear. Continuous glucose monitoring shows a prevalence of hypoglycemia in 75% of patients, with only 1 in 5 being aware they have it. Severe hypoglycemia is estimated to occur in 0.5%. Hypoglycemia is caused by an excess of insulin in response to the actual blood glucose, occurring usually 1-1.5. hours after a meal. This is thought to be the result of increased release of gastrointestinal hormones (incretins), especially glucagon-like peptide 1 (GLP-1), due to the rapid delivery of nutrients, carbohydrates, and proteins to the latter part of the small intestine, which is normally not in contact with less-digested food. Other factors like bacterial overgrowth, diminished antiincretins due to bypassing the proximal small intestine, changing beta-cell structure and/or function, and delayed clearance of insulin could also play a contributing role.Treatment consists of frequent meals, low in carbohydrates, with addition of acarbose in the case of persistence. Somatostatin analogs can also be used. In the case of medical failure, surgical treatment consists of a gastric pouch restriction, addition of a feeding tube into the native stomach, a gastric bypass reversal with or without sleeve resection, or a partial (80%) or total pancreas resection.