Case Presentation: A 69-year-old male with a history of hypertension, chronic pancreatic insufficiency secondary to alcohol use and intraductal papillary mucinous neoplasm. Patient underwent a Whipple procedure which was complicated by recurrent gastro-jejunal anastomotic bleeds that improved after EGD with clipping of stomach ulcer and revision of GJ with conversion to Roux-en-Y, ex-lap and wash-out. 2 months after Roux-en-Y, the patient presented to the hospital with complications of site wound dehiscence and hypoglycemia. During the most recent admission, the patient’s hypoglycemia and associated nausea, vomiting, diarrhea and decreased oral intake were more pronounced, unpredictable and severe. At presentation, laboratory findings showed a glucose level of 15 mg/dL, requiring a D50 infusion with initial response to 90mg/dL, followed by labile levels throughout presentation without clear improvement. As initial dietary modifications (low carbohydrate/high protein) failed, management transitioned to pharmacotherapy with Acarbose which was started at 25mg TID, then titrated to 50mg TID. The patient’s symptoms started to improve dramatically after the initiation of Acarbose. Laboratory findings continued to show stable glucose levels, in the absence of any symptoms of hypoglycemia the patient had experienced during initial presentation including better oral intake, and no nausea or vomiting were reported.
Discussion: Dumping syndrome is commonly observed in patients following bariatric surgery, particularly Roux-en-Y gastric bypass (RYGB). It is classified into two phases: early and late. Early dumping syndrome occurs within the first hour after ingestion of a meal, leading to symptoms like dizziness, palpitations, sweating, and diarrhea. Late dumping syndrome, occurring 1-3 hours after eating, is characterized by hypoglycemia due to the incretin-driven hyper-insulinemic response to an increased influx of glucose. Hypoglycemia in late dumping syndrome presents with symptoms such as shakiness, confusion, and, in severe cases, loss of consciousness. Management strategies aim to slow gastric emptying and prevent rapid carbohydrate absorption. Acarbose, a medication that inhibits alpha-glucosidase enzymes in the small intestine, slowing carbohydrate absorption, has been proposed as a treatment for late-phase hypoglycemia in patients with dumping syndrome. Acarbose has been shown to improve symptomatic hypoglycemia when diet modifications alone are insufficient. Valderas et al. found that in a study of 8 patients who underwent RYGB, a dose of 100 mg of Acarbose taken 15 min before each meal helped reduce symptomatic hypoglycemia. Ritz et al. initiated treatment with Acarbose (50–100 mg TID) for 8 patients experiencing symptomatic hypoglycemia following RYGB, with favorable response and normalized blood glucose levels. Since Acarbose increases the luminal concentration of carbohydrates, common side effects include flatulence, abdominal distention, and diarrhea. These can be minimized by starting a low dose (25 mg) and gradually titrating.
Conclusions: Dumping syndrome is a rare complication following gastrointestinal surgeries. We present the case of a patient with dumping syndrome who developed symptomatic hypoglycemia and was successfully managed with Acarbose which may be a valuable adjunct in preventing symptomatic hypoglycemia in patients at high risk of dumping syndrome, helping to reduce its severity and recurrence when other first-line treatments are inadequate.