My eight week trial of the continuous glucose monitor is on the way, and should be here via UPS on Friday thanks to a very helpful woman at Medtronic, more helpful than my health insurance happened to be anyway.
Once it arrives, I am to literally "hook up" with an educator to teach me how to shoot myself in the gut and keep the sensors from falling out of my loose skin. This is something I had not really thought about, my skin and the sensors. Most of my excess skin is in my abdomen, and that is where the sensors are shown. I hope they have alternate site placement.
Then, off to Old Country Buffet.
Kidding.
I have been doing really well lately, obviously while watching food intake, carb intake tends to go out the window first and those are what trigger the blood sugar the most.
Sure, I still have major fluctuations and can't eat many normal foods (Do not give me a potato!) or any mixed meals (duh) I CAN eat a "low calorie and low carb diet" and not die. But, my brain is still flip-flopping, and I would like to see if blood sugar is at all related to it, because I have been blaming glucose for so very long.
I self-diagnosed since doctors wouldn't listen to me - and I called myself a "reactive hypoglycemic" a couple years ago.
The seizures started after that in the form of complex partials, but have not been linked to blood sugar levels.
Do I think the seizure activity is related to my blood glucose levels? I always have, but it's the what came first thing. I just don't know. I may never know.
But, this trial of the continuous glucose monitor may give us insight - because it will show us a pattern of glucose levels 24/7.
I will be able to track things for myself in conjunction with the graphs the meter saves:
- the partial seizures (any blood sugar changes before)
- any grand mal seizures (any blood sugar changes before)
- reactive hypoglycemia (when I don't have symptoms, which is the reason for the meter)
I am only alloted an eight week use of the meter. So, I was only half-joking about the buffet. I need to sort of trigger events. Life happens. So what if I have been "Very Good" for the last so many weeks? I nearly went comatose a few times in the last few months too, and on some occasions I don't see it coming. I cannot base my entire future with a broken pancreas on six or eight weeks of being on a diet.
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When hyperinsulinemic hypoglycemia persists, continuous glucose
monitoring (CGM) can give a more precise picture of the individual's
blood sugar pattern. The CGM system is worn continuously for three days. It contains a small
catheter that is inserted under the skin to obtain blood glucose
readings every five minutes. Results from the monitor should be
compared to the patient's food and activity log for those days. Blood
glucose that is always low, even during fasting periods, may more
likely indicate a diagnosis of insulinoma, while postprandial
hypoglycemia is probably reflective of more diffuse islet hyperplasia.
Figure 2
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Medtronic CGMS System Gold |
An MRI or CT of the pancreas is needed to rule out insulinoma if the
patient is still symptomatic after the CGM and dietary changes. There
is a case report of a 65-year-old woman who suffered repeated episodes
of hypoglycemia after undergoing gastric bypass for continued weight
gain. Her symptoms were misdiagnosed as dumping syndrome, and a CT and
MRI, which located the tumor, were done only after months of dietary
intervention. It is not certain that she had the insulinoma prior to
her weight loss surgery, but it seems likely, as an OGTT prior to her
operation revealed hypoglycemia. Resection of an insulin-secreting
tumor can be curative. In this case, after surgical removal of the
insulinoma she became symptom-free and remained so going on two years.9
Figure 3
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Patient wearing Medtronic CGMS |
Dietary Treatment
Diet should always be addressed first. Often patients will be able to
recognize some of the foods that cause them difficulty on their own.
Recommendations are to eat a high-fiber diet of three meals plus 1 to 3
snacks daily, to avoid simple sugars (such as juice, soda, and candy),
and to include protein with most of the meals. Protein and fat slow
down carbohydrate digestion and allow blood sugar to remain more
stable. Soluble fibers, such as pectin, guar, and hemicellulose, act by
forming a gel in the intestine, delaying gastric emptying and
prolonging transit time. Dietary recommendations to prevent reactive
hypoglycemia are summarized in Table 1. Hypoglycemic attacks are
treated with pretzels, whole grain cereal, or plain graham crackers. It
may take 3 to 6 weeks for the diet to take effect, but often dietary
changes alone can decrease the incidence and severity of symptoms.
Medical Treatment
A handful of medications have been utilized to treat this condition.
Unfortunately there is a scarcity of information available on use of
medications for hypoglycemic patients who have undergone weight loss
surgery. Medications called a-glucosidase inhibitors, such as acarbose
and miglitol, work by decreasing the absorption of carbohydrates from
the intestine by inhibiting the a-glucosidase enzyme. This results in a
slower and smaller rise in blood sugar. A 78-year-old man experienced
unexplained loss of consciousness (LOC) associated with meals seven
years after partial gastrectomy due to gastric cancer. After OGTT, his
LOC was blamed on late dumping syndrome and he was successfully treated
with acarbose. A second study describes six post-gastrectomy patients
treated with a-glucosidase inhibitors. The medication improved
hypoglycemic symptoms in all patients, but side effects of flatulence
and meteorism were problematic for one patient whose dose needed to be
lowered.10,11
Diazoxide, somatostatin, and prednisolone are other medications that
have been used to treat late dumping. Steroid treatment was successful
in one case report of a patient who was suffering from post-prandial
hypoglycemia after undergoing total gastrectomy with Roux-en-Y
reconstruction for gastric cancer. After being found unconscious, this
51-year-old woman was treated unsuccessfully with both acarbose and
diazoxide before successful treatment with prednisolone. She was on the
medication for three years until she was successfully weaned. She has
remained asymptomatic and off of steroids going on six years.12
Surgical Treatment
There is a role for surgery in cases of nesidioblastosis and
insulinoma.6,13 The latter is considered curative, while the former has
been shown to be helpful in alleviating hypoglycemia. Selective
arterial calcium injections are used to identify areas of hyperplasia.
This allows for guided resection of affected areas. However, there is
controversy over how much pancreas needs to be removed, due to reports
of symptoms returning after subtotal pancreatectomy. It is possible
that total pancreatectomy will be necessary in some cases. It should be
noted that even reversal of gastric bypass may be an ineffective
treatment for this disorder.6,13
Conclusion
The incidence of hyperinsulinemic hypoglycemia following weight loss
surgery appears to be low, but since increasing numbers of weight loss
operations are being performed around the world, we must be on the
forefront when it comes to recognizing and treating the side effects of
these life-saving operations. The exact etiology of this troublesome
condition has yet to be agreed upon. More research needs to be done to
clarify the causes and most effective treatment strategies for this
problematic disorder.
Bariatric Times - ISSN: 1044-7946 - Volume 3 - Issue 9 - December 2006 - Pages: 1 - 12