Delayed Hypoglycemic Encephalopathy after Sleeve Gastrectomy

Abstract

Introduction Hypoglycemic encephalopathy is a potentially life-threatening manifestation of hypoglycemia, It is usually caused by metabolic change, hypoglycemic agents, and malignancy. Here, we report a patient with hypoglycemic encephalopathy caused by sleeve gastrectomy Methods A 34-year-old woman was admitted due to unconsciousness of acute onset. She showed normal corneal and vestibulo-ocular reflex but sluggish pupil light reflex and decerebrated posture by painful stimulation. She has taken severe medications for weight control including orthosiphon powder and hydrochlorothiazide after bariatric surgery. Laboratory studies showed significantly low blood glucose level (13mg/dL) with normal liver enzyme and creatinine. There was no evidence of adrenal insufficiency. Electroencephalography showed no epileptiform discharge. Initial and follow-up brain magnetic resonance imaging revealed diffuse high signal intensity on white matter expanded to cortex, corpus callosum and posterior limb of the left internal capsule, suggesting hypoglycemic encephalopathy. In abdomen-pelvic CT, there is no mass lesion like carcinomas or insulinoma. Results The clinical diagnosis of hypoglycemic encephalopathy followed by sleeve gastrectomy was made by given history of bariatric surgery and the lack of evidence of hypoglycemic agent overdose, adrenal insufficiency, endogenous hyperinsulinism or malignancy. There are several hypotheses that sleeve gastrectomy can encourage hypertrophy of beta cells, hypersecretion of glucagon-like peptide, glucagon abnormality and increased insulin sensitivity, that may induce hypoglycemia. Conclusions We suggest that clinicians should consider sleeve gastrectomy itself as a possible cause of profound Hypoglycemia.