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/m 2 – 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 17 th century Wirsung and 19 th century Bernard • Endocrine function in 19 th century by Langerhans , Miring , and Minkowski • 20 th 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/m 2 – 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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