SAT661 Bypass-oma Or Medication-oma: A Clinical Dilemma About Hypoglycemia
Authors: Perez Hernandez Carlos Alberto , Pesantez Borja Maria Jose , Miranda-Palma Bresta 
Published: October 2023

Abstract
Disclosure: C.A. Perez Hernandez: None. M.J. Pesantez Borja: None.
Introduction With the ongoing worldwide obesity epidemic, the number of bariatric procedures rises every year. Although complications have decreased in the last 20 years, they can result in significant morbidity and mortality. Hypoglycemia is a complication that usually occurs 1-3 years after a Roux-en-Y gastric bypass, and is caused by increased postprandial incretin secretion. Although reported incidence is 0.1%, it is likely underdiagnosed and underestimated cause of hyper insulinemic hypoglycemia. Clinical Case A 33-year-old male with history of pancreatic cancer status post partial pancreatectomy and Roux-en-Y gastric bypass performed 10 years ago, and type 2 diabetes on insulin was admitted for severe persistent hypoglycemia refractory to treatment. He stopped using insulin 6 months ago after passing out while driving 1-2 hours postprandially. Only 2 hours after starting a 72-hour fasting test, the patient had a venous blood glucose of 39 mg/dl. Laboratory results showed: C-peptide:3.3, Insulin:9.3, cortisol:2.6, BHB: 0.5 and proinsulin:3.7; and negative sulfonylurea screening. Dotatate scan was unremarkable. He has started diazoxide, acarbose, octreotide and Everolimus with no improvement to his symptoms. Plan was to repeat the work up, however, the patient refused to cooperate. He also declined a Calcium stimulation test, endoscopic US and bariatric surgery reversal. Review of his imaging studies which, showed no signs of pancreatic surgery. When re-interrogated, medical history inconsistencies were noticed. Hypoglycemia episodes occurred exclusively after being transferred out of ICU, patient was placed in a one-to-one monitoring. During the night shift, he was found injecting himself an unknown medication via PICC line and several medications were found in his room. After being confronted by staff, the Patient left the AMA only to be readmitted the same day for hypoglycemia at another institution. Conclusion Our patient was diagnosed with Munchausen's syndrome, substance abuse and depressive disorder upon evaluation by psychiatry. It was found that 4 years prior to current admission, he completed a 72-hour fasting test in another hospital, without hypoglycemia episodes. However, due to concerns for insulinoma, his oncology team was contacted who reported never having seen the patient or diagnosing with pancreatic cancer. Also, patient was found self-injecting with an unknown medication, and when confronted, he left AMA just like he did while he was under our care. History of self-harm behavior and inconsistencies in medical history may call for atypical presentations of Post Bariatric Surgery hypoglycemia and should prompt a detailed anamnesis and psychiatric assessment. This case represents a clinical dilemma and illustrates the therapeutic challenges encountered with a patient diagnosed with post bariatric surgery hypoglycemia and Munchausen syndrome.
Presentation: Saturday, June 17, 2023