A0029 - A Case of Non-Insulinoma Pancreatogenous Hypoglycemia Syndrome in a Cerebral Palsy Patient Where Diagnosis and Treatment Was Delayed Due to Continuous PEG-Tube Feeding

Saagar Pamulapati, MD¹, Mudassar K. Sandozi, DO², Ammar Aqeel, MD¹, Luqman Baloch, MD³, Naser Khan, MD⁴, Altaf Dawood, MD^3
1MercyHealth System, Rockford, IL; ²MercyHealth Internal Medicine Residency, Rockford, IL; ³MercyHealth Internal Medicine Residency Program, Rockford, IL; ⁴MercyHealth, Rockford, IL

Introduction: Non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS), a rare cause of post-prandial hypoglycemia, presents with neuroglycopenia and negative localization studies for insulinoma. We present a case of NIPHS in a female whose cerebral palsy and continuous tube feeds created difficulty in establishing her diagnosis.

Case Description/Methods: A 22-year-old female with cerebral palsy (baseline nonverbal status and quadriplegia) presented to the hospital with 5 days of lethargy. She had no fevers or seizures at home and had been on continuous enteral nutrition via PEG tube for two years. Vitals were normal. Physical exam showed decreased responsiveness and absent spontaneous eye opening on top of baseline posturing and muscle spasticity. Infectious workup was negative. Labs found a decreased blood glucose of 72mg/dl. As patient’s mentation improved overnight, hospital tube feeds were restarted at a reduced rate. Patient’s morning blood glucose was 66mg/dl so tube feeding rate was increased. Blood glucose further declined to 42mg/dl a few hours later. Continuous dextrose infusions, high carbohydrate tube feeds, and continuous glucagon drip were administered with minimal benefit. Insulin, proinsulin, and c-peptide were found to be within normal range. Insulin antibody test was also negative. Abdominal ultrasound and CT found no lesions in the pancreas or other acute pathology. Patient was deemed to have NIPHS. Acarbose was initiated with resolution of hypoglycemia and improvement in mentation and patient was discharged home with no further complications.

Discussion: The postprandial hypoglycemia differential in non-nondiabetic patients includes insulinoma, post bariatric surgery hypoglycemia, dumping syndrome, insulin autoimmunity, postprandial syndrome, and NIPHS. Our patient’s cerebral palsy and nonverbal status masked the neuroglycopenic symptoms typical in NIPHS. Continuous home tube feeds via PEG initially prevented us from determining the postprandial timing of her lethargy. These clues could have pointed us in the direction of NIPHS sooner which would have allowed for more prompt utilization of acarbose, earlier discharge and avoidance of the use of dextrose infusions, glucagon, and high carbohydrate tube feeds. The high carbohydrate diet likely worsened our patient’s condition as reports indicate free carbohydrate reduction improves the clinical status of NIPHS patients. Fortunately, we were able to administer acarbose to resolve our patient’s condition without incident.


Disclosures:


Saagar Pamulapati, MD¹, Mudassar K. Sandozi, DO², Ammar Aqeel, MD¹, Luqman Baloch, MD³, Naser Khan, MD⁴, Altaf Dawood, MD³. A0029 - A Case of Non-Insulinoma Pancreatogenous Hypoglycemia Syndrome in a Cerebral Palsy Patient Where Diagnosis and Treatment Was Delayed Due to Continuous PEG-Tube Feeding, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.