Bariatric surgery Flashcards
dumping syndrome
Constellation of symptoms due to rapid movement due to the altered anatomy. seen in 50% of Roux en Y gastric bypass surgery. can be late or early based on timing and etiology of post-prandial symptoms.
Early dumping syndrome timing and causes
see symptoms within 15-30 minutes of eating and see abdominal pain, diarrhea, nausea. This is rapid emptying of hypertonic gastric contents into small intestine which can also see rapid fluid shifts between the plasma and high osmolality of the bowel.
Early dumping syndrome presentation
15-30 minute post prandial see abdominal pain, diarrhea, nausea. see hypotension and tachycardia too.
Late dumping syndrome timing and causes
this happens 2-3 hrs after eating and from surge of insulin. See pts are hyperglycemic due to speedy transit and absorption of simple carbs into the small intestine, but this is then countered by surge of insulin causing hypoglycemia. Here we can see severe post prandial hypoglycemia that can cause loss of consciousness or seizure.
Late dumping syndrome presentation
diziness, confusion, fatigue and diaphoresis from hypoglycemia.
initial management of people with dumping syndrome
for both early and late dumping syndrome: eating small frequent meals and replacing simple sugars with complex carbohydrates and incorporating high fiber and protein rich foods in diet.
internal hernia can occur in RYGB surgery as
abdominal pain, small bowel obstruction or strangulation and occurs in 5% of all surgeries
short bowel syndrome happens after
massive resection of small bowel. See malabsorptive diarrhea with nutrient deficiencies and dehydration and weight loss.
stomal stenosis presents with
nausea/vomiting, GERD, dysphagia after procedure and seen in 6 to 20% of roux en Y gastric bypass surgeries
Symptoms of acquired copper deficiency?
related to gastric surgery
See leukopenia, anemia, (normocytic, microcytic, macrocytic), osteoporosis, and neurological symptoms. fragile hair, skin depigmentation, muscle weakness and ataxia. See neuropathy similar to vitamin B12 deficiency. Can also see positive Babinski (bilateral extensor plantar reflex)
How can zinc supplementation cause copper deficiency with patients who have history of bariatric surgery?
increased zinc intake can compete with copper absorption into the GI tract.
causes of acquired copper deficiency
gastric surgery, prolonged total parenteral nutrition,
excessive zinc ingestion, malabsorptive enteropathies (celiacs dx, inflammatory bowel dx)
how to confirm diagnosis of low copper levels?
low serum copper and ceruloplasmin levels
How to improve neurological deficits related to acquired copper deficiency
stop zinc supplements and supplement with copper
B12 deficiency on labs
see high MCV and normocytic anemia and borderline B12 deficiency
if pt has neurological symptoms and normocytic anemia why is less likely that folate deficiency is a cultprit?
because folate deficiency doesn’t cause neurological symptoms
presentation of copper deficiency
ataxia, spasticity with muscle weakness, positive Romberg and Babinski, dorsal column dx
Consideration of B12 deficiency too
When do we get nerve conduction studies if concerned for muscle weakness related to malabsorption?
when we have documented low copper levels
complication/presentation of Vitamin B12 deficiency
see macrocytic anemia
cognitive defects
peripheral neuropathy - loss of vibratory sense and proprioception
Roux-en Y gastric bypass has complications regarding malabsorption with:
doesn’t affect macronutrient absorption but can have micronutrient absorption:
deficiencies in Ca, Fe, vitamin B12, fat soluble vitamins (A D E K) and thiamine and folate
fat soluble vitamins are
vitamin A, D, E, K
how to correct vitamin B12 deficiency related to Roux En Y gastric bypass?
daily oral supplementation can help reverse neuropathy. IV and IM vitamin B12 who do not improve with supplementation
how to monitor vitamin B12 levels in gastric bypass?
should be done 3 months post surgery, 6 months and annually after RYGB.
vitamin A deficiency clinical presentation:
night or complete blindness, poor bone growth, dermatological issues, immune deficiencies
Zinc deficiency presentation
abdominal pain, anorexia, depression compromised wound healing and immune dysfunction
can see alopecia and night blindness too
calcium deficiency from roux en y gastric bypass.
see osteopenia, metabolic bone disease, secondary hyperparathyroidism
thiamine deficiency in a roux en y gastric bypass surgery:
intractable vomiting and Wernicke’s encephalopathy
indications for bariatric surgery
BMI>40 without comorbidities
BMI 35-40 kg/m2 with >1 comorbid illness (DM2 and HTN, HLD)
what is the best treatment for controlling A1c in one year in someone with uncontrolled DM2 and severe obesity >35
see this with Roux en Y gastric bypass and does work more than medical therapy
what is small intestinal bacterial overgrowth
often seen in post bariatric surgery and seen with bloating, flatulence, diarrhea, macrocytic anemia
SIBO (small intestinal bacterial overgrowth) clinical presentation
abd pain and distension, discomfort, flatulence, and diarrhea
see malabsorption, weight loss, anemia (b12 deficiency) and vitamin deficiency
complications of prolonged or severe SIBO
fat malabsorption leading to steatorrhea, weight loss and nutritional deficiencies (A D B1 and B12)
what causes SIBO (small intestinal bacterial overgrowth)
anatomical abnormalities (Strictures and surgery) motility disorders (DM2, scleroderma)
Diagnosis of SIBO (small intestinal bacterial overgrowth)
Jejunal aspirate and culture showing >10^5 organisms/ml
or
carbohydrate breath testing (lactulose and glucose)
organisms that cause SIBO (small intestinal bacterial overgrowth)
streptococci, bacteriodes, E coli, Lactobacillus
treatment of SIBO (small intestinal bacterial overgrowth)
antibiotics (rifaximin, amoxicillin-clavulanate)
avoid anti motility agents like narcotics
dietary changes (high fat low carbs)
promotility agents
how does bariatric surgery predispose someone to having recurrent urolithiasis?
due to calcium oxalate stones caused by hyperoxaluria and hypocitrauria.
Malabsorption causes more intestinal fatty acid to bind to calcium which increases colonic oxolate absorption and renal oxalate excretion.
why is there less citrate in urine in pts who have had bariatric surgery?
Malabsorption causes low urinary citrate for unclear reasons. Perhaps it’s because of hypokalemia or chronic metabolic acidosis from malasorptive diarrhea leading to increased citrate reabsorption in renal proximal tubule.
citrate is an inhibitor of kidney stones and so less hypocitraturia and hyperoxalauria causes rise of kidney stones by 4% per year
how to treat presence of oxalate kidney stones in bariatric surgery pt
need to have a low oxalate diet and exogenous citrate supplementation.
what causes calcium oxalate kidney stones?
Crohn’s and bariatric surgery
stromal stenosis at the gastro-jejunal anastomosis can happen when
3-6 months post Roux en Y bypass surgery
common complication that happens in 5-20% of pts
symptoms and clinical presentation of stromal stenosis?
see n/v, abd pain, and GERD, dysphagia, and eventual inability to tolerate oral intake.
diagnosis of stromal stenosis at the gastro jejunal anastomosis
how to treat
EGD
then can do serial dilations with endoscopic balloon to widen the narrowing.
Common complication as a result of rapid weight loss with roux en y gastric bypass surgery?
cholelithiasis seen in as much as 40% of pts.
how to decrease risk for cholelithiasis after bariatric surgery
can give ursodeoxycholic acid for up to 6 months after surgery
is gastroparesis a side effect of bariatric surgery
no.
Top three complications following bariatric surgery
dumping syndrome, gastro-jejunal stromal stenosis, and cholelithiasis.
bariatric surgery pts should be on these supplements:
vitamin B12, calcium, multivitamin (for ADEK) at minimum
consider Iron and folate
macrocytosis and fatigue and no neurological symptoms that presents weeks to months after bariatric surgery
consider folate deficiency
make sure that there is
in someone who is post bariatric surgery who presents with symptomatic anemia, what is the most likely cause for the anemia?
iron deficiency
B12 deficiency
folate deficiency
or copper deficiency?
most likely it will be Iron but see if there are other clues
iron is absorbed via the duodenum and upper portion of the jejunum.
however this is the area that is bypassed.
should consider copper too.
Treatment of iron deficiency post bariatric surgery is:
oral iron (ferrous sulfate) and if this does not work then can give IV iron (2g iron dextran)
what medication should pts who have had bariatric surgery avoid?
NSAIDS- because of increased risk for internal bleeding.
what medication adjustments should be made after bariatric surgery?
need to keep a close eye on their blood pressure and diabetic medications
will need a dose reduction in BP and diabetic meds as they lose weight.
