SUN-578 - Recurrent Severe Post–Bariatric Hypoglycemia After Sleeve Gastrectomy in a 21-Year-Old Woman

Background:
Post–bariatric hypoglycemia (PBH) is increasingly recognized after metabolic surgery and is
classically associated with Roux-en-Y gastric bypass (RYGB). Epidemiologic data suggest PBH
is uncommon when defined by hospitalization ( < 1%) but affects up to 30% of patients by
symptom questionnaires and 25–75% by continuous glucose monitoring (CGM), with higher
rates after RYGB than sleeve gastrectomy (SG). The burden after SG is less well characterized.

Case Presentation:
A 21-year-old female with a previous history of SG one year ago, presented with episodes of
dizziness, weakness, visual changes, and cold extremities. Fingerstick blood glucose (BG)=40-
48 mg/dL, done by the paramedics. She was administered ½ ampule of D50 with transient
improvement. In the Emergency Department, there was recurrent hypoglycemia (hypo) requiring
hospital admission. She recalled milder, postprandial episodes during the first 3–4 months after
SG, relieved by eating, but BG was never measured.
During hospitalization, nocturnal hypoglycemia was not present. Thyroid function, ACTH, and
cortisol levels were normal. Oral hypoglycemic screening was negative. During a symptomatic
event BG= 65 mg/dL with insulin 9.3 µIU/mL (NL=2.6 - 24.9), beta-hydroxybutyrate 0.1 mmol/L,
normal proinsulin (9.2 pmol/L) (NL=7.2 - 22), negative insulin autoantibodies, arguing against
insulinoma and supporting PBH diagnosis. A low-carbohydrate, high-protein diet with small,
frequent meals, separation of liquids from solids, and acarbose 25 mg twice daily, and a
Dexcom G7 were recommended. The patient was readmitted 7 days later for recurrent
symptomatic hypoglycemia. Acarbose was then increased to 25 mg three times daily and
nutrition counseling reinforced. The patient did not have any further significant episodes of
hypoglycemia prompting hospital admission

Discussion:
Randomized data shows that reactive hypoglycemia occurs in approximately 29% of RYGB,
and 14% of SG patients 12 months postop. Hospitalizations for symptomatic hypoglycemia has
been reported after RYGB but not SG, thus supporting a higher risk and greater severity with
RYGB, while confirming that SG still confers substantial PBH risk. Large series and consensus
statements further estimate PBH in up to one-third of post-bariatric patients depending on
definition and testing modality, underscoring that SG is not exempt. This case extends these
observations to a young, otherwise healthy patient whose PBH after SG also caused
neuroglycopenic symptoms and repeat hospital admissions.

Conclusion:
Severe PBH can occur after SG and should be considered in young patients with postprandial
neuroglycopenic symptoms. CGM-guided monitoring, structured dietary modification, and
pharmacologic therapy, such as acarbose are central to management and may reduce
recurrence and hospitalization.

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