Case Report
Insulinoma-Induced Hypoglycemia in a Patient With Nesidiodysplasia After Vagomotomy and Pyloroplasty for Duodenal Ulcer

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Abstract

A 45-year-old woman was referred to us for hypoglycemia. The patient had been operated on for a duodenal ulcer by bilateral troncular vagotomy and pyloroplasty 20 years ago and, since then, she showed a dumping syndrome. Two months before consultation she developed repetitive episodes of symptomatic hypoglycemia. An oral glucose tolerance test showed hypoglycemia with endogenous hyperinsulinism. The continuous glucose monitoring system sensor demonstrated fasting hypoglycemia. The endoscopic ultrasound of the pancreas showed a pancreatic tumor that was confirmed in the pathologic study after surgery. Moreover, nesidiodysplasia image was found surrounding pancreatic parenchyma. We report, for the first time, both histologic lesions associated in a patient with a history of vagotomy and pyloroplasty for a duodenal ulcer and we discuss the possible pathogenic mechanisms.

Section snippets

CASE REPORT

A 45-year-old woman was referred to us for symptomatic hypoglycemia (capillary blood glucose of 25 and 30 mg/dL). She underwent troncular vagotomy and pyloroplasty for duodenal ulcer 20 years ago. After surgery, she developed a dumping syndrome with tachycardia, palpitations, feeling nausea, diarrhea, dizziness, trembling, and hyperhidrosis, approximately 15 to 20 minutes after meals lasting 60 to 90 minutes. Two months before her initial visit, the patient began with episodes of sweating, tremor,

DISCUSSION

To the best of our knowledge, this is the first report of a patient with insulinoma-induced hypoglycemia associated with nesidiodysplasia after vagotomy and pyloroplasty for peptic ulcer. This disorder was manifested both by fasting hypoglycemia and by postprandial hyperinsulinemic hypoglycemia (insulin ≥3 μU/mL and C-peptide ≥0.6 ng/mL with concomitant glucose level <55 mg/dL and the absence of sulfonylureas in serum).1

The relationship between the development of endogenous hyperinsulinemic

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