A Patient Presenting With Symptoms Of Hypoglycemia

A 32-year-old female presents to your office complaining of “hypoglycemia.” She notices that about
2–3 hours after a meal she gets nauseated, shaky, and irritable. When she wakes up in the morning, she generally feels well even though she eats dinner at about 5:00 PM and does not eat any snacks afterward and generally does not have breakfast until 8:00 AM.

You can tell her that:
A) She likely has an insulinoma.
B) She likely will have normal blood sugars when she feels shaky.
C) Hypoglycemia does not exist as an entity in this form and she likely has anxiety.
D) She likely has “fasting” hypoglycemia.
E) None of the above.

Discussion

The correct answer is “E.”

“A” is incorrect because a patient with an insulinoma should be hypoglycemic after a 15-hour fast (5:00 PM–8:00 AM).

“B” is incorrect. This patient may have postprandial hypoglycemia that occurs 2–4 hours after eating. The process leading to postprandial hypoglycemia is as follows: the patient has a large meal with simple carbohydrates, the serum insulin level increases in response but overshoots, and the patient becomes transiently hypoglycemic for 15–20 minutes 2–4 hours after eating. This is associated with adrenergic outpouring in an attempt to correct the problem. It is the adrenergic outpouring that causes the symptoms of tremor, nausea, etc.

“C” is incorrect because hypoglycemia does exist.

“D” is incorrect. The patient does not have symptoms of fasting hypoglycemia, which occur 4–6 hours (or longer) after the last meal.