Possible Post-Prandial Reactive Hypoglycemia & Possible Issues re: Iron, Blood or Liver

Cliffnotes:

I more than likely have post-prandial reactive hypoglycemia, as well as something going on with my iron (or my liver?), and I'm looking for useful information about what to do next.

The Unabridged, Tl; Dr; Version:

I'm now five years out from my RnY, and some symptoms I just thought were related to my hypertension (like light-headedness) and I was experiencing that heart flutter thing, which we've been possibly incorrectly thinking was hormonal (I'm 47). But there are so many other symptoms I have been experiencing (both before and after my bypass), which I think either have been dismissed or not considered connected to the bypass, i.e. anxiety, depression, insomnia, ****asional) night terrors, (somewhat) blurred vision, fatigue, et al.

On 1/18/16 I had a routine 2 hour glucose tolerance test. My fasting glucose is always perfect, A1C and insulin both are on the low side of normal.  The day of the test, my fasting glucose was 90 (normal!), and after two hours, it bottomed out at 32. However, after the test, I honestly felt fine. Had no idea anything was wrong. It was only later on when my doctor called me in a panic, did I know something was going on.    

The endocrinologist required that I start monitoring my glucose, sent me home with a One Touch and instructed me how to use it. Day 1, I had to stick myself six times (when in reality I think I should have stuck myself 12 times) as my doc wanted me to test fasting before each meal and 2 hours after; only problem is, I didn't tell him I actually eat roughly six times a day. So I'm sure all the sticks I did yesterday are probably inaccurate; however what glucometer readings I have had have been consistently normal, and the only oddball results were following a snack of rum cake (I know! Mama needs her flavor!), and another reading after 1/2 a grapefruit. Both of these dipped me into the 60s.

Nearly all of my readings 2 hours after eating have been normal, as well as my numbers when I wake up in the a..m. (Normal for me: 88-94 have been the norm).

Prior to all of this, the only indication I knew something was up was the fact I feel like crap eating something like bagels, pizza, or pasta, so for me, since the bypass, I thought it was a normal progression to get away from those foods--so that's how I manage that (BY AVOIDING THEM). 

Without knowing with some certainty of what's going on bio-chemically, all along I have been managing this eating smaller meals (hindsight: sometimes I guess TOO small/unsubstantial), focusing on proteins, and avoiding a lot of refined high glycemic carbs.

I cannot help but be discouraged, as I haven't lost everything I wanted (I lost 100, rebounded/regained 25), and have worked hard just to maintain what I have, and tried so hard not to become a diabetic, and now THIS. I pack a feed bag for work, and am pretty regimented with eating six times a day, remaining compliant about the no liquids after eating restriction, as well as staying on top of all my vitamin requirements etc.

Other possible considerations for the dip in glucose for the test (Or as I call it, "The Perfect Storm"):

1. I was on a cruise the previous week, and I was using scopolamine transdermal patches I wear for seasickness.
2. Being post-op compliant (or so I thought!), when I have a ****tail, it's always before I eat food.
3. I'm on a collection of supplements, each of which can lower glucose: evening primrose oil, Relora, and milk thistle.

On a hunch, I googled "post-prandial hypoglycemia, Roux en Y," and here I am. 

I'm just really dejected and not sure how to handle the news/possibility of this as a diagnosis. I was hoping after ditching the supplements and avoiding alcohol for a bit (mind you I do 1-2 drinks a week), perhaps we can do a hyperglucidic breakfast test to know with certainty of the diagnosis. I was also more than a bit miffed that my endocrinologist wasn't open to checking to see if the lab still had my blood samples available to: retest the results; as well as run a test to see what my epinephrine and glucagon levels were before/after the OGTT.

There is some inconsistency from my doctors regarding which diagnosis is THE diagnosis:

Bariatric guy thinks it's "classic dumping syndrome."
Endocrinologist thinks it's post-prandial reactive hypoglycemia.

To be honest, I wi**** were dumping syndrome, but my gut tells me it's not.

NOW ABOUT THE IRON ISSUE...

My blood test performed on the same day, right before the OGTT was administered:

RBC was high: 5.27
Hematocrit was high: 48.3
MCHC was low: 31.6

However, on my blood test results from three months prior, everything was fine.

I'm not seeing a hematologist (yet), and perhaps I should consider seeing one (on top of everything else, I have Factor Five Leiden Mutation (heterozygous), but not symptomatic). 

Note: To date, I still have my thyroid, which is chock full of (at the moment, benign) nodules. The only thing off was my thyroglobulin result was low: 0.1 .

I sincerely thank you if you made it this far and finished reading and mentally processing this!!! And I look forward to any USEFUL advice or information you might be able to offer up.

I read it all, but have no advice, as I'm a pre-op and a newbie here! I'm a RN though too and your situation sounds incredibly complex! Best of luck to you as you try to sort it out.

Post op RNY long term RH (reactive hypoglycemia) is very common.  Very very old news.. Study showed post op RNY most of us makes too much insulin in response to carbs sugars. Solution - limit carbs and sugars and don't eat meals that are just carbs. 

Very very common.... Seach reactive hypoglycemia on OH.. 

Iron - b12 - wonder why they did not test the whole iron panel... 

Some of us have problem absorbing iron orally and need I fusions every once in a while... 

Total iron panel - make sure the doc orders test for ferritin... 

To control RH I limit carbs and increase fat in my diet. Simply following lower carbs - moderate proteins and fat diet...  Even natural sugar in fruits and veggies is still sugar... So I limit that... Meat, fish, eggs, non starchy veggies... No grains... 

Clarification:  Full panel and then some was run. The numbers listed in my post were just the numbers which were irregular and out of range.  I didn't want to post all my numbers as ALL my other levels were within their respective normal ranges, and my post was long enough as it was.

Typically speaking, what carbs I do eat tend to be of the lower glycemic variety (no white, fluffy, over-refined carbs here), and I'm not eating meals top heavy in them. And fruit isn't something I eat every day. Basically I'm doing everything I should be doing, and still problems are unavoidable.

Insulin levels both fasting and 2 hours after OGTT were on the low end of normal.

Yea... I understand... I have that... Any carbs - even the so called fiber can cause that. Plus lean proteins. Our body needs insulin to process proteins. 

Google food insulin index.  Fat does not require insulin. 

My typical meal to avoid low blood sugars is app 20 grams or less of proteins,  5-10 gr of carbs, 10-20gr of fat. That works good for me. I do deal with severe RH.. If I don't follow those rules. Of I eat proteins I do need some carbs to help with the low sugars 1-2 hrs after the meal... It is the way my body deals with food now... 

http://www.lenoxhillhospital.org/press_releases.aspx?id=2106

Do we fail the surgery or is the surgery failing us?

Delete Edit

Aug 30, 2011

New Data on Weight Gain Following Bariatric Surgery

Gastric bypass surgery has long been considered the gold standard for weight loss. However, recent studies have revealed that this particular operation can lead to potential weight gain years later. Lenox Hill Hospital's Chief of Bariatric Surgery, Mitchell Roslin, MD, was the principal investigator of the Restore Trial - a national ten center study investigating whether an endoscopic suturing procedure to reduce the size of the opening between the gastric pouch of the bypass and the intestine could be used to control weight gain in patients following gastric bypass surgery. The concept for the trial originated when Dr. Roslin noticed a pattern of weight gain with a significant number of his patients, years following gastric bypass surgery. While many patients could still eat less than before the surgery and become full faster, they would rapidly become hungry and feel light headed, especially after consuming simple carbohydrates, which stimulate insulin production.

The results of the Restore Trial, which were published in January 2011, did not confirm the original hypothesis - there was no statistical advantage for those treated with suturing. However, they revealed something even more important. The data gathered during the trial and the subsequent glucose tolerance testing verified that patients who underwent gastric bypass surgery and regained weight were highly likely to have reactive hypoglycemia, a condition in which blood glucose drops below the normal level, one to two hours after ingesting a meal high in carbs. Dr. Roslin and his colleagues theorized that the rapid rise in blood sugar - followed by a swift exaggerated plunge - was caused by the absence of the pyloric valve, a heavy ring of muscle that regulates the rate at which food is released from the stomach into the small intestine. The removal of the pyloric valve during gastric bypass surgery causes changes in glucose regulation that lead to inter-meal hunger, impulse-snacking, and consequent weight regain.

Dr. Roslin and his team decided to investigate whether two other bariatric procedures that preserve the pyloric valve - sleeve gastrectomy and duodenal switch - would lead to better glucose regulation, thus suppressing weight regain. The preliminary data of this current study shows that all three operations initially reduce fasting insulin and glucose. However, when sugar and simple carbs are consumed, gastric bypass patients have a 20-fold increase in insulin production at six months, compared to a 4-fold increase in patients who have undergone either a sleeve gastrectomy or a duodenal switch procedure. The dramatic rise in insulin in gastric bypass patients causes a rapid drop in glucose, promoting hunger and leading to increased food consumption.

"Based on these results, I believe that bariatric procedures that preserve the pyloric valve lead to better physiologic glucose regulation and ultimately more successful long-term maintenance of weight-loss," said Dr. Roslin.

PS: My ferritin was 36. Within range.

36 is just ok. I now get innfused when Mine dropps below 30...  I star having symptoms of low iron when my ferritin drops below 50.. I like mine 80-150. 

If proper diet does not help with your BS - ask the doc to check you for adrenal insufficiency. 

I have that issue and my body does not make enough cortisone. So now I am on small dose of steroids to supplement what my body does not make. 

Cortisone is nessesary to properly control and level BS. Too much is not good - not enough - hypoglycemia and sometimes difficult to control RH.  

I have secondary adrenal insufficiency.  Mild case..but enough to cause issues. 

Everything you said about the cortisone (for me I focus on cortisol) and the adrenal stuff, I totally understand. And this is also the second concern I have about my endocrinologist because when I asked him if we could contact the lab (as I know they usually keep the samples for a short period of time) to see if they could both, re-test the OGTT, as well as run epinephrine and glucagon levels to see if there was any adrenal activity or involvement, given the A1C and insulin levels were both on the low side of normal. His response: Not at this time. Well, if I'm not going to go through another OGTT, when would we be able to collect that information? I think there could have been useful information gathered if we did that.

Moving forward, I doubt I'll ever have to go thru another OGTT again, and now that I know better, if I have to have one again, I will refuse to do so unless it's in a hospital setting.

What you describe in not dumping.  Your endocrinologist is correct in identifying it as reactive hypoglycemia.  It is common after RNY and can be controlled by diet.