Unintended consequences of bariatric surgery the changing face of a familiar disease

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Unintended consequences of bariatric surgery
the changing face of a familiar disease

• Andrea Braun MD
• Thomas S. Huddle MD
• Division of General Internal Medicine

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Learning Objectives

• Impact of bariatric surgery on nutritional
  deficiencies
• Neurologic complications after bariatric surgery

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Course of illness in 26 year old Caucasian Female

• progressive bilateral lower extremity weakness
• inability to walk
• Blurred and double vision
• Mental sluggishness
• personality changes

150 lbs weight loss
Day 1
Month 4
Month 3 1/2
Multiple admissions for nausea, vomiting,
abdominal pain, dehydration
Bariatric surgery (Roux-en-Y gastric bypass)
Admission
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Other Pertinent History

• PMH
• morbid obesity
• asthma
• hypertension
• depression, anxiety
• Medications
• Paroxetine, Quetiapine, Alprazolam
• Fosinopril
• PRN albuterol and atrovent inhalers
• Social History No tobacco, alcohol or drugs
• Family History noncontributory

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Physical Exam

• VS BP 146/98 HR 111 RR 22 T 99.1ºF
• Obese Caucasian female with flat affect, tearful
• Neurological exam
• Unable to walk 2/5 strength and areflexia in
  both lower extremities
• bilateral ophthalmoplegia
• Spontaneous horizontal nystagmus
• Normal upper extremity strength and reflexes
• Normal sensory exam
• Normal rectal sphincter tone

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Diagnostic considerations

• Neuromuscular disorder
• Myopathy / Myositis
• Myelopathy
• Neuropathy
• Multiple sclerosis
• Guillain-Barre Syndrome
• Conversion disorder
• Vitamin or nutritional deficiency

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Diagnostic Evaluation

• Normal routine labs, CK, RPR, ANA, HIV antibody

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Evaluation of metabolic and nutritional
deficiencies

• Normal Vitamin B12, Vitamin A, Vitamin E, Zinc,
  Selenium

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Clinical Diagnosis

• Wernickes Encephalopathy
• secondary to
• thiamine deficiency

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Hospital Course and Follow-Up

• Initiation of daily IV thiamine and multivitamin
  therapy
• gradual improvement over several months
• Complete resolution of ophthalmoplegia and
  nystagmus
• Partial improvement in bilateral lower extremity
  weakness

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Wernickes Encephalopathy

• Historically most commonly observed in alcoholism
• Classical Triad (seen in only 16)
• ocular changes (ophthalmoplegia, nystagmus)
• ataxia
• encephalopathy / mental status changes

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Epidemiology

• Prevalence in autopsy series 0.82.8
• Male Female Ratio 1.7 1
• Mortality 17
• Diagnosis missed in 75-80 of autopsy-confirmed
  cases in alcoholics or AIDS patients
• 80 of survivors develop Korsakoff Syndrome

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Pathophysiology
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Clinical settings

• Chronic alcohol abuse and malnutrition
• Unbalanced nutrition (e.g. polished rice)
• Gastrointestinal surgical procedures
• Recurrent vomiting and diarrhea
• Cancer
• Systemic diseases
• Renal disease
• AIDS
• Thyrotoxicosis
• Chronic infectious diseases

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Prevention and Treatment of Wernickes
Encephalopathy

• Recommended daily dose of thiamine in healthy
  adults 1.4 mg/day
• Requirements are higher in children, critical
  illness, pregnancy, lactation
• Treatment dose 100mg thiamine IV

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Thiamine deficiency after gastric bypass surgery

• 18.3 incidence of thiamine deficiency one year
  after gastric bypass surgery
• 0.4 of all patients developed Wernickes
  encephalopathy
• 28 of patients with neurologic complications
  after bariatric surgery suffer from Wernickes
  encephalopathy or Wernicke-Korsakoff syndrome

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Summary

• Thiamine deficiency is common after bariatric
  surgery
• Thiamine deficiency can lead to Wernickes
  Encephalopathy in some patients
• Prompt treatment with intravenous thiamine
• Prophylactic supplementation with vitamins and
  minerals after bariatric surgery
• Familiar disease patterns present in new patient
  populations

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References

• Incidence of Vitamin Deficiency after
  laparoscopic Roux-en-Y Gastric Bypass in a
  University Hospital Setting. Clements R et al. Am
  Surg 721196-1204 2006
• Neurologic complications after surgery for
  obesity. Koffman B et al. Muscle Nerve
  33166-176 2006
• Nutritional and metabolic complications of
  bariatric surgery. Malinowski S. Am J Med Sci
  331(4)219-225 2006
• Nutrient deficiencies secondary to bariatric
  surgery. Alvarez-Leite J. Curr Op Clin Nutr Met
  Care 7569-575 2004
• Wernicke encephalopathy after obesity surgery A
  systematic review. Singh S et al. Neurology
  68807-811 2007
• Wernickes encephalopathy new clinical settings
  and recent advances in diagnosis and management.
  Sechi G et al. Lancet Neurol 6442-455 2007
• Nutritional Neuropathies. Kumar N. Neurol Clin
  25209-255 2007
• Vitamin and Trace Mineral Levels after
  Laparoscopic Gastric Bypass. Madan A et al.
  Obesity Surg 16603-606 2006

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Questions