title: Hypoglycaemia following upper gastrointestinal surgery: case report and review of the literature.
abstract: BACKGROUND
  Hyperinsulinemic hypoglycemia is relatively recently recognized in persons undergoing bariatric surgery although knowledge and experience with this condition may not be commensurate with the number of such procedures being performed globally. This paper presents a novel case as an example of how such patients may present and how they may be investigated.
  
  
  METHODS
  A 69-year-old man was assessed 3 months post-fundoplication surgery for postprandial hypoglycaemia with neuroglycopenia that became progressively severe. A 72-h fast failed to show hypoglycaemia. During a clinic visit, the patient became confused and had a low plasma glucose, high plasma insulin, and high plasma C-peptide; symptoms were relieved with glucose. No tumours were visualized on CT, MRI, or endoscopic ultrasound. A total body Indium111-octreotide scan was negative. Selective arterial calcium stimulation showed a high insulin gradient in the splenic and superior mesenteric arteries, suggesting diffuse pancreatic beta cell hyperplasia. The patient declined pancreatic resection and recurrent symptomatic hypoglycaemia was successfully prevented with low dose octreotide.
  
  
  CONCLUSIONS
  Although increasingly recognized following bariatric surgery, this is the first reported development of NIPHS (non-insulinoma pancreatogenous hypoglycemia syndrome) following fundoplication surgery, as well as the first documented use of octreotide in post-operative NIPHS. Medical management may be an alternative to surgery for patients with this rare condition.
authors.affiliation: Division of Endocrinology, Faculty of Medicine, University of Calgary, Calgary, Alberta Canada.
authors.forename: Brandon
authors.initials: B
authors.lastname: Bernard
authors.forename: Gregory A
authors.initials: GA
authors.lastname: Kline
authors.forename: F John
authors.initials: FJ
authors.lastname: Service
mesh_terms: D000368:Aged; D001786:Blood Glucose / Q000378:metabolism; D004305:Dose-Response Relationship, Drug; D018662:Fundoplication / Q000009:adverse effects*; D005765:Gastrointestinal Agents / Q000627:therapeutic use; D006801:Humans; D007003:Hypoglycemia / Q000175:diagnosis* / Q000188:drug therapy / Q000209:etiology*; D007328:Insulin / Q000097:blood; D008297:Male; D015282:Octreotide / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D001786:Blood Glucose; D005765:Gastrointestinal Agents; D007328:Insulin; D015282:Octreotide