(18.15) A Rare Case of Postprandial Hypoglycemia after Surgical Repair of Hiatal Hernia with Nissen Fundoplication

Reactive postprandial Hypoglycemia is a well-known complication after bariatric surgery. Although a few case reports have been described in children, it is rare in adults after gastrointestinal procedures like Nissen fundoplication. Hyperinsulinemia due to excessive secretion of glucagon like peptide-1 (GLP-1) has been described in neonates after Nissen fundoplication, but the mechanism in adults remains unclear.

Case(s) Description :

We report a 75-Year-old male with a history of obesity, large hiatal hernia and severe Gastroesophageal reflux disease (GERD) symptoms refractory to medical therapy. He underwent laparoscopic surgical repair of the hiatal hernia along with Nissen fundoplication. Four months later, he presented with recurrent episodes of weakness, dizziness, shakiness and sweating occurring around 2 hours after his meals. Fingerstick glucose during his symptoms confirmed low glucose < 50 mg/dl on multiple occasions. His symptoms resolve after drinking juice but then recur every time he eats. His labs after 12 hours of fasting showed Glucose of 105 mg/dl, with elevated Insulin 31.8 uIU/ml and elevated C-peptide 5.03 ng/ml. His HBA1C was 5.2% and his AM serum Cortisol was normal 18.7 ug/dl. He was started on a continuous glucose monitoring (CGM) which showed recurrent postprandial hypoglycemia throughout the daytime, but no fasting hypoglycemia. Abdomen CT with IV contrast showed no pancreatic lesions. He was advised low-carb, high-protein small frequent meals. In addition, he was started on Acarbose 25 mg before each meal with significant improvement in his Hypoglycemia.

Discussion :

Postprandial Hyperinsulinemic Hypoglycemia is not limited to bariatric surgery.  Although rare, it may occur after anti-reflux surgeries such as Nissen fundoplication and can pose significant patient morbidity. CGM is a valuable tool to help recognize the postprandial pattern of hypoglycemia. It is important for clinicians to be aware of this potential complication and its treatment options to allow early recognition and proper management. Targeting Incretin hormone pathway like GLP-1 receptor may be a promising future treatment option of this condition.