FRI080 Post Bariatric Hypoglycemia And Pregnancy: Successful Utilization Of Remnant Stomach Gastrostomy Tube Placement In Severe Refractory Hypoglycemia After Roux-en-Y Gastric Bypass Surgery
Authors: Habbsa Samima Sultana , Port Ava 
Published: October 2023

Abstract
Disclosure: S.S. Habbsa: None. A. Port: None.
Introduction: Post bariatric hypoglycemia (PBH) can occur following Roux-En-Y Gastric Bypass (RYGB). Due to an exaggerated glucagon-like-peptide-1 (GLP-1) response from rapid nutrient transit to the distal bowel, patients with PBH exhibit endogenous hyperinsulinemic hypoglycemia following a carbohydrate load. Severe cases can result in significantly impaired quality of life (QoL), including syncope, seizures, and nutritional deficits from restricted intake. Recently, remnant stomach percutaneous endoscopy gastrostomy (PEG) tube placement has been reported in a handful of cases as a successful long-term strategy for RYGB-PBH refractory to nutritional and medical therapy. However, there are no known outcomes in pregnancy. Case: A 25-year-old female with a history of RYGB presented with increasingly severe and frequent PBH beginning 12 months after surgery. Mixed meal testing was consistent with prandial hypoglycemia (down to 20 mg/dL) with hyperinsulinemia (C-peptide 11 [0.80 - 3.10 ng/mL], Insulin 50 [&lt;23 uIU/mL]). Ultrasound was negative for pancreatic anomalies. Dietary modification and medical therapy with acarbose, diazoxide, and liraglutide were unsuccessful. 3 years after RYGB, she required hospitalization for hypoglycemic seizures, and she underwent remnant stomach PEG tube placement. Oral intake was discontinued (except for protein for comfort) and substituted with 12-hour nocturnal feeds. Her PBH diminished, and she reported significant improvement in QoL. 6 years after PEG placement, the patient became pregnant. Working closely with a dietician, she increased caloric intake by 200-250 kcal/day in the second and third trimesters. Screening for gestational diabetes with oral glucose tolerance testing was deferred given risk of PBH exacerbation, and CGM was used instead for glycemic monitoring. Intolerance to overnight feeds was remedied using concentrated enteral formulas and incorporation of short daytime tube feed boluses. She delivered a healthy baby via elective C-section. During lactation, due to concern for food protein allergy, she was transitioned to a non-dairy non-soy-based feeding regimen. She returned to her pre-pregnancy weight and her sugars remained stable. Conclusion: This is the first case report documenting safe and effective use of remnant stomach enteral feeds for management of severe refractory PBH post RYGB during pregnancy and lactation. Pregnancy presents a unique situation in which increased carbohydrate intake is necessary to support fetal development; however, this can be life-threatening for patients with severe PBH. Remnant stomach PEG feeds utilize the original gut without need for surgical RYGB reversal, preventing rapid nutrient transit. Long-term reversal of PBH, sustained weight loss and customizable feeding regimens support the use of remnant PEG placement for severe RYGB-PBH in the appropriate patient.
Presentation: Friday, June 16, 2023