A unique case of hypoalbuminemia after gastric bypass Roni - - PowerPoint PPT Presentation

A unique case of hypoalbuminemia after gastric bypass

Roni weisshof Gastroenterology department, Rambam Health Care Campus, Haifa

Background

• 53 y/o
• 2010:

– Morbid obesity – 123kg; BMI 43.9 kg/m2 – Hypertension – Diabetes mellitus type 2 – Hyperlipidemia – Obstructive sleep apnea – Fatty liver

Background

• 1/2011 - Laparoscopic bariatric gastric

bypass

– Bypass of 50 cm distal to treitz ligament – Normal course – Normal recovery – Discharge – no nutritional recommendation

Background

• 7/11

– 35 kg weight reduction – First complain of “weakness” after meals – Dizziness, gait problems – Diabetes improvement

• Insulin reduction till discontinuation
• Medication reduction
• HgA1C – 6%

– Vitamin D (25 OH) - 15.5 ng/mL – Total cholesterol – 107 mg/dl

Background

• Treatment

– Multivitamin – Vit. D – Vit. E – Diabetic drug reduction – Statin termination

Background

• 12/2012:

– 45 kg weight reduction – HgA1C - 4.5% – Hypoalbuminemia – 2.8 gr/dl – Candidate for plastic surgery – abdominoplasty

Current illness

• 6/2013 – First visit to gastro outpatient clinic

– 50 kg weight reduction – stable – No HLP or DM – Taking multivitamins – Multiple bowel movements – Neuropathy – Severe peripheral edema – Albumin – 2.8 gr/dl – Normal cholesterol; lymphocytes; BUN; UA

Current illness

• Went trough investigation
• 11/2013 – abdominoplasty + liposuction
• DM “exacerbation”
• Leg edema
• 1/2014 – hospitalization for investigation

Current illness

• Physical:

– Generally well, soft abdomen, open wound in mid abdomen, no

• tenderness. Bilateral leg edema – lt >> rt. Otherwise normal

– Weight – 80 kg

• Lab:

– Hgb - 11.7, MCV – 83, WBC – 9.7; PLT – 301; LYM – 1.7 – TP – 6; ALB – 2; BUN – 6; CR – 0.64; CHOL – 87 – TSH – 3.3; HgA1C – 6.9% – INR – 1.17 – VIT D (25) – 23

• USD:

– Evidence of DVT in proximal and distal veins of left leg

Summery

• 56 y/o patient
• DM
• S/P gastric bypass
• Diarrhea
• Hypoalbuminemia
• Peripheral edema
• “Exacerbation” of DM

Differential diagnosis

Malabsorption - surgery

• Short bypass
• 5.6% - 25% diarrhea
• Abate over time (12 months < 24 months)
• 1 group – improvement in bowel habits up to

5y

Obes Surg. (2008) 18:1287–1296 Obes Surg. 1997 Aug;7(4):337-44 Obes Surg. 2009 Jan;19(1):56-65 Surg Obes Relat Dis. 2009 Sep-Oct;5(5):553-8

Malabsorption - surgery

• Relatively low rate of protein caloric

malnutrition

• Specific nutrients:

– Calcium and Vit. D – Iron – B12

Dumping syndrome

• Nausea, abdominal pain, diarrhea up to 90%
• Post-prandial feeling faint/weakness – 40%
• Malnutrition – rare
• Up to 75.9 % of pt. after gastric bypass
• Early - subsides within 12 to 18 months
• No relationship between dumping and weight

loss after surgery

Dig Dis Sci (2010) 55:117–123 J Clin Gastroenterol. 2004 Apr;38(4):312-21. Obesity Surgery, 1996, Volume 6, Issue 6, pp 474-47 Obes Surg. 1996 Dec;6(6):474-478

Bacterial overgrowth

• 25 - 40% after RNYGB (breath test)
• Stasis and gastric acid
• Anemia (B12)
• Fat soluble vitamins
• Caloric malnutrition

Aliment Pharmacol Ther. 2014 Sep;40(6):582-609 Obes Surg. 2007;17:752–8. Obes Surg.(2008) 18:139–143

IBD

• Case reports
• Short period after surgery
• Most women
• Microbiome ?

Endocr Pract. 2012 Mar-Apr;18(2):e21-5 BMJ Case Reports 2011; doi:10.1136/bcr.07.2010.3168 Infl amm Bowel Dis 2005 ; 11 : 622 – 4

Others

• Gastro-colic fistula
• Celiac
• Eating disorder
• ……

Workup

• Urine – no protein
• BNP – normal
• Abdominal CT – normal
• Gastroscopy – with small bowel biopsy -

normal

• Colonoscopy – with TI biopsy - normal
• USD lt. limb – proximal and distal DVT

Workup

• Stool sample

– Culture + parasites – negative – Fatty acids: +++ – Neutral fats: +++ – Elastase: 62 µg/gr (7/13) --- 17 µg/gr (2/14)

Workup

• A diagnosis of pancreatic exocrine

insufficiency (PEI) was made:

– Enteral feeding – Pancreatic enzymes – Multivitamins – Anticoagulation – Micronutrient assessment

• PEI - 25-50% SBO

– Rifaximin

Abdominal CT

Abdominal CT

CA 19-9 – normal EUS ? Biopsy ? Follow up ? Other ?

Abdominal MRI

Pancreas history

• From Greek - Pan: all; Kreas: flesh or meat)
• First described by Herophilus (335–280 BC)
• Named by Rufus of Ephesus ~ 100 AD

The American Journal ol Surgery, Volume 146, November 1993

Pancreas history

• Exocrine function in 17th century Wirsung

and 19th century Bernard

• Endocrine function in 19th century by

Langerhans, Miring, and Minkowski

• 20th century - 5 Nobel prizes

GASTROENTEROLOGY 2013;144:1166 –1169

Pancreas exocrine insufficiency Etiology

WJG 2013, November 14; 19(42): 7258-7266

Pancreas exocrine insufficiency Diagnosis

• Gold standard -– Coefficient of fat

absorption - not practical

• Background
• Clinical picture
• Imaging
• Laboratory findings, elastase, breath test
• Pancreatic enzyme trail
• High clinical suspicion – 6.1% of IBS-D

J Biol Chem 1949; 177: 347-355 JGH, 2013; 28 (Suppl. 4): 99–102 Clin Gastroenterol Hepatol. 2010 May;8(5):433-8

Pancreas exocrine insufficiency Diagnosis

Pancreatology 2013; 13: 38-42

Pancreas insufficiency treatment

• Indications:

– Severe symptoms – Fecal fat > 15 g/day

WJG 2013, November 14; 19(42): 7258-7266

Pancreas insufficiency treatment

Pancreas insufficiency and gastrectomy

• Common - up to 67% clinically steatorrhea
• 3 months after total gastrectomy – human

Significantly reduced secretion of:

– Trypsin – 89% – Chymotrypsin – 91% – Amylase – 72%

• More in Roux-en-Y reconstruction (mice)
• Food passage through the duodenum

Scand J Gastroenterol 1979;14:401–407 Aliment Pharmacol Ther. 1988 Dec;2(6):493-500 Am J Gastroenterol. 1996 Feb;91(2):341-7

Pancreas insufficiency and gastrectomy

• Empiric pancreatic enzyme replacement

therapy – clinical benefit after gastrectomy

– More benefit for massive steatorrhoea

• Pathological glucose tolerance

Aliment Pharmacol Ther. 1988 Dec;2(6):493-500 Pancreatology 2001;1(suppl 1):41–48

Pancreas insufficiency and gastrectomy

WJG, Nov 14, 2013; 19(42): 7258–7266

Back to the patient –treatment

• Oral treatment with pancreatic enzymes –

slow progression

– TPN for 1 month – Higher dose of pancreatic enzymes – Multivitamin – Dietician follow up and recommendation

Follow up

• 3/2014

– Overall improvement – normal life activity – Normal bowel habits – Weight improvement – Edema reduction – Abdominal wound healing – Normal CBC – Albumin – 4 gr/dl – Iron deficiency, other micronutrients – normal – DM – HgA1C – 7.7%

Follow up

• 8/2014

– Normal bowel habits – Weight – 89 kg; BMI – 30.8 kg/m2 – Mild leg edema – Albumin – 3.7 gr/dl – No micronutrient deficiency expect mild vit. D – HgA1C – 6.4% – Sus. SOL in rt. Kidney – follow up meanwhile

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