Approach to the patient with postprandial hypoglycemia

Postprandial hypoglycemia in a nondiabetic patient is a frequent chief complaint across all medical specialties and represents a significant diagnostic challenge.

We conducted an electronic and print literature search using PubMed for articles published in the last 40 years using the key words "postprandial hypoglycemia," "reactive hypoglycemia," and "hyperinsulinemic hypoglycemia." All available sources were reviewed, and publications were included based on clinical relevance.

Over the last century, the classification, etiologies, diagnosis, and management of hypoglycemia have evolved considerably. In the contemporary literature, the evaluation of hypoglycemia is divided into well-appearing and ill-appearing patients. Symptoms of hypoglycemia in the well-appearing patient may result from insulinoma, noninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS), postbariatric surgery hypoglycemia, dumping syndrome, insulin autoimmunity, or postprandial syndrome. For each of these, the literature is lacking in randomized clinical trials investigating optimal diagnostic and treatment modalities, and this is due to the relatively recent description of some diseases and the rarity of cases.

This review provides an overview of postprandial hypoglycemia and summarizes the proposed pathophysiologic mechanisms of postprandial hypoglycemia, with special attention paid to some of the more recently described syndromes, such as NIPHS and postbariatric surgery hypoglycemia. Diagnostic and management strategies are also discussed.