Erika Paniago Guedes

Insulinoma Misdiagnosed as Dumping Syndrome after Bariatric Surgery

Background: Late dumping syndrome is a possible side-effect of gastric bypass. Hypoglycemic symptoms may develop 3-4 hours after certain types of foods.There may exist patients, however, who present hypoglycemia in the absence of dumping syndrome. The presence of only mild symptoms of hypoglycemia may make the evaluation of these patients difficult and delay the identification of other possible sources of hyperinsulinemia, including an insulinoma. Case Report: A 65-year-old woman underwent gastric bypass for continued weight gain and morbid obesity. After surgery, the patient had repeated episodes of hypoglycemia, diagnosed at follow-up as late dumping syndrome. The persistence of hypoglycemic episodes after nutritional counseling and modifications in the feeding pattern led to consideration of an autonomous source of hyperinsulinemia, and MRI and CT identified insulinoma. After a laparotomy and pancreatic tumor resection, she remains free of symptoms. Conclusion: Hypoglycemic episodes after obesity surgery are not always related to dumping syndrome. The persistence of hypoglycemia in spite of nutritional counseling should raise the possibility that there may exist other causes. Insulinoma, the most common cause of endogenous hyperinsulinemia, should be investigated in these patients, since it is a tumor that can be cured.

Aspectos neuroendócrinos da síndrome metabólica

The metabolic syndrome (MS) is characterized by alterations in carbohydrate metabolism, obesity, hypertension and dislipidemia. These metabolic alterations interfere with some endocrine axes controlled by the hypothalamus and the pituitary. Central obesity might be associated to a state of subclinical hypercortisolism and hypertension, secondary to an activation of the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system. MS is also a state of relative hyposomatotropism, probably related to visceral fat. Furthermore, high levels of free fat acids and hyperinsulinemia, secondary to insulin resistance, can contribute to a blockade of the somatotropic axis. In men, MS is related to a state of hypogonadism caused by impairment in gonadotropin secretion and testosterone production. Women exhibit excessive androgen production, secondary to hyperinsulinemia, high levels of LH and to an increase in aromatase activity. In summary, MS is a condition linked to important modifications in feedback mechanisms responsible for the correct functioning of the neuroendocrine axes.

Management of obesity in adolescents: state of art.

Increasing prevalence of obesity in children and adolescents might represent an emerging public health issue. Pathogenesis of obesity is multifactorial and involves a complex interplay of genetic and environmental factors. Adolescent obesity has been seen as a cosmetic problem only; nevertheless, a significant increase in cardiovascular risk, probably due to obesity-related metabolic disarrangement has been observed. Consequently, discussion on strategies for treating childhood and adolescent obesity has been promoted worldwide. The proposed treatment triad is life style modification, pharmacological, and surgical treatment. Although lacking definitive data, drug therapy has emerged as an efficacious tool, at least in adolescent obesity. Therefore, sibutramine and orlistat may be good therapeutic options when life style modifications alone do not work.

Lean mass as a predictor of bone density and microarchitecture in adult obese individuals with metabolic syndrome

The effects of obesity and metabolic syndrome (MS) on bone health are controversial. Furthermore, the relationship between body composition and bone quality has not yet been determined in this context. The aim of this study was to investigate the correlations between body composition and bone mineral density (BMD) and bone microstructure in obese individuals with MS. This cross-sectional study assessed 50 obese individuals with MS with respect to their body composition and BMD, both assessed using dual X-ray absorptiometry, and bone microarchitecture, assessed by high-resolution peripheral quantitative computed tomography (HR-pQCT) of the distal tibia and radius. Several HR-pQCT measurements exhibited statistically significant correlations with lean mass. Lean mass was positively correlated with parameters of better bone quality (r: 0.316-0.470) and negatively correlated with parameters of greater bone fragility (r: -0.460 to -0.310). Positive correlations were also observed between lean mass and BMD of the total femur and radius 33%. Fat mass was not significantly correlated with BMD or any HR-pQCT measurements. Our data suggest that lean mass might be a predictor of bone health in obese individuals with MS.

Serum TSH levels are associated with cardiovascular risk factors in overweight and obese adolescents

OBJECTIVE To investigate the relationship between serum thyrotropin (TSH), insulin resistance (IR), and cardiovascular risk factors (CRF) in a sample of overweight and obese Brazilian adolescents. METHODS A retrospective, longitudinal analysis of 199 overweight and obese pubescent adolescents was performed. The TSH and free T4 (fT4) levels, anthropometric measurements, and laboratory test results of these patients were analyzed. RESULTS 27 individuals (13.56%) presented with TSH levels above the normal level (subclinical hypothyroidism [SCH]). Their waist circumference (WC) was significantly higher than those of euthyroid individuals. Serum TSH was positively correlated with the homeostasis model assessment of insulin resistance (HOMA-IR) index, triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C). Using TSH and BMI as independent variables, TSH levels were shown to be independently related to HOMA-IR (p=0.001) and TG (p=0.007). Among euthyroid subjects, individuals with TSH values <2.5mIU/mL exhibited statistically significant decreases in waist-to-hip ratio, HDL-C levels, and HOMA-IR scores and a tendency toward lower WC values. CONCLUSION SCH in overweight and obese adolescents appears to be associated with excess weight, especially visceral weight. In euthyroid adolescents, there appears to be a direct relationship between TSH and some CRF. In conclusion, in the present sample of overweight and obese adolescents, TSH levels appear to be associated with IR and CRF.

Symptomatic bacterial contamination of an intragastric balloon

Commentary The prognosis of patients with primary malignant melanoma of the esophagus is poor, and the mean survival is under 1 year. I might speculate the typically grim prognosis of this exceptionally rare cancer (representing perhaps 1 in a thousand esophageal cancers) is multifactorial: an insidious growth pattern resulting in delayed detection (at which point there might be metastases), misclassification (and perhaps inappropriate or ineffective treatment), and, of course, plain old aggressive tumor biology. About half of the hapless patients with esophageal melanoma already in fact have metastatic disease, and the routes of early dissemination are both lymphatic and vascular. Melanoma, both primary and metastaticd especially the amelanotic variety (a term not be confused with the absence of upper GI bleeding)dhas secured its place on the “great imitator” list and can be confused with small cell carcinoma, epidermoid carcinoma, and sarcoma. Excision of the typically pigmented and polypoid lesion, whether surgical or endoscopic, is the only chance of cure. The authors, whose endoscopic sangfroid is hard to ignore, note this is the first reported case of successful ESD for primary malignant esophageal melanoma, and I’m not about to disagree. David Robbins, MD, MSc Assistant Editor for Focal Points

Impact of Weight Loss With Intragastric Balloon on Bone Density and Microstructure in Obese Adults

The historical concept that obesity protects against bone fractures has been questioned. Weight loss appears to reduce bone mineral density (BMD); however, the results in young adults are inconsistent, and data on the effects of weight loss on bone microstructure are limited. This study aimed to evaluate the impact of weight loss using an intragastric balloon (IGB) on bone density and microstructure. Forty obese patients with metabolic syndrome (mean age 35.1 ± 7.3 yr) used an IGB continuously for 6 mo. Laboratory tests, areal BMD, and body composition measurements via dual-energy X-ray absorptiometry, and volumetric BMD and bone microstructure measurements via high-resolution peripheral quantitative computed tomography were conducted before IGB placement and after IGB removal. The mean weight loss was 11.5%. After 6 mo, there were significant increases in vitamin D and carboxyterminal telopeptide of type 1 collagen levels. After IGB use, areal BMD increased in the spine but decreased in the total femur and the 33% radius. Cortical BMD increased in the distal radius but tended to decrease in the distal tibia. The observed trabecular bone loss in the distal tibia contributed to the decline in the total volumetric BMD at this site. There was a negative correlation between the changes in leptin levels and the measures of trabecular quality in the tibia on high-resolutionperipheral quantitative computed tomography. Weight loss may negatively impact bone microstructure in young patients, especially for weight-bearing bones, in which obesity has a more prominent effect.

Pharmacotherapy in Childhood Obesity

Publisher Summary Childhood obesity had been viewed as simply a cosmetic problem, and major risks were only considered when the weight excess persisted into adulthood. Recently, however, overweight and obesity in childhood are known to have a significant impact on both physical and psychosocial health. Discussion on strategies of treating childhood and adolescent obesity has been promoted worldwide, and a variety of scientific articles have been published on this topic. Prevention and effective treatment of obese children and adolescents must be a priority. The cornerstone of health promotion in childhood and adolescence is healthy lifestyle behaviors and therapeutic lifestyle change. As emphasized in pediatric guidelines for cardiovascular health and risk reduction, patterns of dietary intake and physical activity for a majority of children and adolescents are not meeting current recommendations. In most studies, adolescents typically remain overweight after conventional therapy. In contrary, short-term pharmacological therapy was found to be beneficial in obese adolescents, according to some studies. These findings have important clinical relevance and may provide additional treatment options for overweight children and adolescents, especially those with a history of unsuccessful weight loss with traditional therapies.