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Unintended consequences of bariatric surgery  – the changing face of a familiar disease Andrea Braun MD  Thomas S. Huddle ...
Learning Objectives <ul><li>Impact of bariatric surgery on nutritional deficiencies </li></ul><ul><li>Neurologic complicat...
Course of illness in 26 year old Caucasian Female  <ul><li>progressive bilateral lower extremity weakness </li></ul><ul><l...
Other Pertinent History <ul><li>PMH:   </li></ul><ul><ul><li>morbid obesity </li></ul></ul><ul><ul><li>asthma </li></ul></...
Physical Exam <ul><li>VS : BP 146/98  HR 111  RR 22  T 99.1 º F  </li></ul><ul><li>Obese Caucasian female with flat affect...
Diagnostic considerations <ul><li>Neuromuscular disorder </li></ul><ul><li>Myopathy / Myositis </li></ul><ul><li>Myelopath...
Diagnostic Evaluation <ul><li>Normal routine labs, CK, RPR, ANA, HIV antibody </li></ul>normal Nerve conduction studies ac...
Evaluation of metabolic and nutritional deficiencies <ul><li>Normal Vitamin B12, Vitamin A, Vitamin E, Zinc, Selenium </li...
Clinical Diagnosis <ul><li>Wernicke’s Encephalopathy  </li></ul><ul><li>secondary to  </li></ul><ul><li>thiamine deficienc...
Hospital Course and Follow-Up <ul><li>Initiation of daily IV thiamine and multivitamin therapy </li></ul><ul><li>gradual i...
Wernicke’s Encephalopathy <ul><li>Historically most commonly observed in alcoholism </li></ul><ul><li>Classical Triad  (se...
Epidemiology <ul><li>Prevalence in autopsy series: 0.8–2.8% </li></ul><ul><li>Male : Female Ratio = 1.7 : 1 </li></ul><ul>...
Pathophysiology
Clinical settings <ul><li>Chronic alcohol abuse and malnutrition </li></ul><ul><li>Unbalanced nutrition (e.g. polished ric...
Prevention and Treatment of Wernicke’s Encephalopathy <ul><li>Recommended daily dose of thiamine in healthy adults: 1.4 mg...
Thiamine deficiency after gastric bypass surgery <ul><li>18.3 % incidence of thiamine deficiency one year after gastric by...
Summary <ul><li>Thiamine deficiency is common after bariatric surgery  </li></ul><ul><li>Thiamine deficiency can lead to W...
References <ul><li>Incidence of Vitamin Deficiency after laparoscopic Roux-en-Y Gastric Bypass in a University Hospital Se...
Questions
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2008.02.19 Braun.ppt

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2008.02.19 Braun.ppt

  1. 1. Unintended consequences of bariatric surgery – the changing face of a familiar disease Andrea Braun MD Thomas S. Huddle MD Division of General Internal Medicine
  2. 2. Learning Objectives <ul><li>Impact of bariatric surgery on nutritional deficiencies </li></ul><ul><li>Neurologic complications after bariatric surgery </li></ul>
  3. 3. Course of illness in 26 year old Caucasian Female <ul><li>progressive bilateral lower extremity weakness </li></ul><ul><li>inability to walk </li></ul><ul><li>Blurred and double vision </li></ul><ul><li>Mental sluggishness </li></ul><ul><li>personality changes </li></ul>Day 1 Bariatric surgery (Roux-en-Y gastric bypass) Admission 150 lbs weight loss Multiple admissions for nausea, vomiting, abdominal pain, dehydration Month 4 Month 3 1/2
  4. 4. Other Pertinent History <ul><li>PMH: </li></ul><ul><ul><li>morbid obesity </li></ul></ul><ul><ul><li>asthma </li></ul></ul><ul><ul><li>hypertension </li></ul></ul><ul><ul><li>depression, anxiety </li></ul></ul><ul><li>Medications: </li></ul><ul><ul><li>Paroxetine, Quetiapine, Alprazolam </li></ul></ul><ul><ul><li>Fosinopril </li></ul></ul><ul><ul><li>PRN albuterol and atrovent inhalers </li></ul></ul><ul><li>Social History: No tobacco, alcohol or drugs </li></ul><ul><li>Family History: noncontributory </li></ul>
  5. 5. Physical Exam <ul><li>VS : BP 146/98 HR 111 RR 22 T 99.1 º F </li></ul><ul><li>Obese Caucasian female with flat affect, tearful </li></ul><ul><li>Neurological exam: </li></ul><ul><ul><li>Unable to walk; 2/5 strength and areflexia in both lower extremities </li></ul></ul><ul><ul><li>bilateral ophthalmoplegia </li></ul></ul><ul><ul><li>Spontaneous horizontal nystagmus </li></ul></ul><ul><ul><li>Normal upper extremity strength and reflexes </li></ul></ul><ul><ul><li>Normal sensory exam </li></ul></ul><ul><ul><li>Normal rectal sphincter tone </li></ul></ul>
  6. 6. Diagnostic considerations <ul><li>Neuromuscular disorder </li></ul><ul><li>Myopathy / Myositis </li></ul><ul><li>Myelopathy </li></ul><ul><li>Neuropathy </li></ul><ul><li>Multiple sclerosis </li></ul><ul><li>Guillain-Barre Syndrome </li></ul><ul><li>Conversion disorder </li></ul><ul><li>Vitamin or nutritional deficiency </li></ul>
  7. 7. Diagnostic Evaluation <ul><li>Normal routine labs, CK, RPR, ANA, HIV antibody </li></ul>normal Nerve conduction studies acute mixed neurogenic and myopathic denervation in proximal muscles EMG nonspecific moderately severe type II fiber atrophy Muscle biopsy mildly elevated protein (82 mg/dL), no oligoclonal bands Lumbar puncture normal MRI spine small focal areas of enhancement along the medial aspects of both thalami MRI brain
  8. 8. Evaluation of metabolic and nutritional deficiencies <ul><li>Normal Vitamin B12, Vitamin A, Vitamin E, Zinc, Selenium </li></ul>Low Vitamin D 44 nM / L (normal 87-280) Thiamine levels Low Vitamin C Low Vitamin B6 Low Vitamin B2 (riboflavin)
  9. 9. Clinical Diagnosis <ul><li>Wernicke’s Encephalopathy </li></ul><ul><li>secondary to </li></ul><ul><li>thiamine deficiency </li></ul>
  10. 10. Hospital Course and Follow-Up <ul><li>Initiation of daily IV thiamine and multivitamin therapy </li></ul><ul><li>gradual improvement over several months </li></ul><ul><li>Complete resolution of ophthalmoplegia and nystagmus </li></ul><ul><li>Partial improvement in bilateral lower extremity weakness </li></ul>
  11. 11. Wernicke’s Encephalopathy <ul><li>Historically most commonly observed in alcoholism </li></ul><ul><li>Classical Triad (seen in only 16%): </li></ul><ul><ul><li>ocular changes (ophthalmoplegia, nystagmus) </li></ul></ul><ul><ul><li>ataxia </li></ul></ul><ul><ul><li>encephalopathy / mental status changes </li></ul></ul>
  12. 12. Epidemiology <ul><li>Prevalence in autopsy series: 0.8–2.8% </li></ul><ul><li>Male : Female Ratio = 1.7 : 1 </li></ul><ul><li>Mortality: 17% </li></ul><ul><li>Diagnosis missed in 75-80% of autopsy-confirmed cases in alcoholics or AIDS patients </li></ul><ul><li>80% of survivors develop Korsakoff Syndrome </li></ul>
  13. 13. Pathophysiology
  14. 14. Clinical settings <ul><li>Chronic alcohol abuse and malnutrition </li></ul><ul><li>Unbalanced nutrition (e.g. polished rice) </li></ul><ul><li>Gastrointestinal surgical procedures </li></ul><ul><li>Recurrent vomiting and diarrhea </li></ul><ul><li>Cancer </li></ul><ul><li>Systemic diseases: </li></ul><ul><ul><li>Renal disease </li></ul></ul><ul><ul><li>AIDS </li></ul></ul><ul><ul><li>Thyrotoxicosis </li></ul></ul><ul><ul><li>Chronic infectious diseases </li></ul></ul>
  15. 15. Prevention and Treatment of Wernicke’s Encephalopathy <ul><li>Recommended daily dose of thiamine in healthy adults: 1.4 mg/day </li></ul><ul><li>Requirements are higher in children, critical illness, pregnancy, lactation </li></ul><ul><li>Treatment dose: 100mg thiamine IV </li></ul>
  16. 16. Thiamine deficiency after gastric bypass surgery <ul><li>18.3 % incidence of thiamine deficiency one year after gastric bypass surgery </li></ul><ul><li>0.4% of all patients developed Wernicke’s encephalopathy </li></ul><ul><li>28% of patients with neurologic complications after bariatric surgery suffer from Wernicke’s encephalopathy or Wernicke-Korsakoff syndrome </li></ul>
  17. 17. Summary <ul><li>Thiamine deficiency is common after bariatric surgery </li></ul><ul><li>Thiamine deficiency can lead to Wernicke’s Encephalopathy in some patients </li></ul><ul><li>Prompt treatment with intravenous thiamine </li></ul><ul><li>Prophylactic supplementation with vitamins and minerals after bariatric surgery </li></ul><ul><li>Familiar disease patterns present in new patient populations </li></ul>
  18. 18. References <ul><li>Incidence of Vitamin Deficiency after laparoscopic Roux-en-Y Gastric Bypass in a University Hospital Setting. Clements R et al. Am Surg 72:1196-1204; 2006 </li></ul><ul><li>Neurologic complications after surgery for obesity. Koffman B et al. Muscle & Nerve 33:166-176; 2006 </li></ul><ul><li>Nutritional and metabolic complications of bariatric surgery. Malinowski S. Am J Med Sci 331(4):219-225; 2006 </li></ul><ul><li>Nutrient deficiencies secondary to bariatric surgery. Alvarez-Leite J. Curr Op Clin Nutr Met Care 7:569-575; 2004 </li></ul><ul><li>Wernicke encephalopathy after obesity surgery: A systematic review. Singh S et al. Neurology 68:807-811; 2007 </li></ul><ul><li>Wernicke’s encephalopathy: new clinical settings and recent advances in diagnosis and management. Sechi G et al. Lancet Neurol 6:442-455; 2007 </li></ul><ul><li>Nutritional Neuropathies. Kumar N. Neurol Clin 25:209-255; 2007 </li></ul><ul><li>Vitamin and Trace Mineral Levels after Laparoscopic Gastric Bypass. Madan A et al. Obesity Surg 16:603-606; 2006 </li></ul>
  19. 19. Questions

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