Accepted Manuscript Secondary Kwashiorkor: A Rare Complication of Gastric Bypass Surgery Jeffrey H. William , M.D, Elliot B. Tapper , M.D, Eric U. Yee , M.D, Simon C. Robson , M.B., Ch.B., Ph.D PII:
S0002-9343(14)01149-8
DOI:
10.1016/j.amjmed.2014.12.002
Reference:
AJM 12794
To appear in:
The American Journal of Medicine
Received Date: 20 November 2014 Revised Date:
2 December 2014
Accepted Date: 2 December 2014
Please cite this article as: William JH, Tapper EB, Yee EU, Robson SC, Secondary Kwashiorkor: A Rare Complication of Gastric Bypass Surgery, The American Journal of Medicine (2015), doi: 10.1016/ j.amjmed.2014.12.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Title: Secondary Kwashiorkor: A Rare Complication of Gastric Bypass Surgery Authors:
RI PT
Jeffrey H. William, M.D.1 Elliot B. Tapper, M.D. 2 Eric U. Yee, M.D.3 Simon C. Robson, M.B., Ch.B., Ph.D.2 1
Department of Medicine, Division of Nephrology, Beth Israel Deaconess Medical Center Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center 3 Department of Pathology, Beth Israel Deaconess Medical Center
Corresponding author: Jeffrey William, MD Beth Israel Deaconess Medical Center 185 Pilgrim Road, Farr 8 Boston, MA 02215 E-mail: [email protected]
M AN U
SC
2
TE D
Funding source(s) related to this manuscript: None
Conflict of interest statement: None of the authors of this manuscript have any potential conflicts of interest, financial, personal, or otherwise.
EP
Author verification: All authors had access to the details of the case and a role in writing the manuscript.
AC C
Classifications: gastroenterology, obesity, nutrition, surgery References: 4 Figures: 1
Word length of abstract: 128 Word length of manuscript: 485 (including references)
1
ACCEPTED MANUSCRIPT
Abstract
RI PT
Bariatric surgery often improves health outcomes for morbidly obese patients and is increasing in popularity. While functional malabsorption is less common with modern surgical techniques, the procedure can still contribute to acquired food intolerance and maladaptive eating
SC
behaviors that can precipitate or worsen pre-existing nutritional deficiencies. When severe, this can lead to protein-energy malnutrition, or kwashiorkor. While more common in resource-poor
M AN U
countries, it is also an under-recognized form of malnutrition in hospitalized patients in Western countries. Herein, we describe a 42-year-old woman status post Roux-en-Y gastric bypass surgery with secondary kwashiorkor, characterized by edema, dermatoses, exocrine pancreatic insufficiency and hepatosteatosis. Longitudinal, multidisciplinary care involving
TE D
surgeons, internists, and dietitians can provide a supportive environment for those at risk for
AC C
EP
nutritional complications after bariatric surgery and subsequent maladaptive eating behaviors.
2
ACCEPTED MANUSCRIPT
To the Editor:
RI PT
Kwashiorkor is a form of severe protein malnutrition that rarely affects adults in developed nations. However, protein-energy malnutrition is likely under-recognized among hospitalized patients in Western countries for whom it is often secondary to non-dietary causes of
SC
malnutrition including malabsorption, chronic alcoholism, kidney disease, severe burns, and
M AN U
bariatric surgery.1
Herein, we describe a 42-year-old woman status post Roux-en-Y gastric bypass surgery with secondary kwashiorkor characterized by edema, dermatoses, exocrine pancreatic insufficiency
Case Report
TE D
and hepatosteatosis (Figure 1, Panel A).
EP
A 42-year-old female with a history of a Roux-en-Y gastric bypass surgery in 2001 was transferred to our hospital with cachexia and anasarca. Her post-operative course had been
AC C
marked by early satiety and poor nutritional intake over the next 10 years. Months prior to admission, she developed malodorous stools along with an enlarging abdomen followed by anasarca with weeping blisters and erythema. Physical exam found temporal wasting, scleral icterus, angular cheilosis, with thinning and depigmented hair. The skin over her body was free of spider angiomata and palmar erythema, but her fingertips were peeling with a purple discoloration. The abdomen was distended with shifting dullness, but without caput medusae. 3
ACCEPTED MANUSCRIPT
Laboratory studies were as shown in Figure 1, Panel B. Endoscopy revealed duodenal villous blunting. Percutaneous liver biopsy demonstrated severe hepatosteatosis and inflammation
RI PT
without Mallory hyaline inclusions, consistent with non-alcoholic steatohepatitis given her lack of alcohol intake and strong collateral history.
SC
Discussion
Secondary kwashiorkor after bariatric surgery may be an under-recognized etiology of
M AN U
malnutrition, which can develop following self-prescribed modifications in diet to achieve greater weight loss by substituting whole foods and protein with carbohydrate-rich, highcalorie alternatives. Kwashiorkor has numerous entities demonstrated by our patient, including: (1) hepatosteatosis secondary to decreased hepatic synthesis of plasma beta-
TE D
lipoproteins and intestinal epithelial-barrier dysfunction leading to hepatic necroinflammation,2 (2) exocrine pancreatic insufficiency due to the high rate of protein turnover, (3) edema secondary to ineffective hepatic inactivation of ADH and ferritin release from damaged
EP
hepatocytes promoting further increased ADH secretion and hyperaldosteronism,3 and (4) dermatoses, represented by changes in hair characteristics (depigmented and brittle) along
AC C
with a multitude of skin findings from an array of combinations of vitamin and micronutrient deficiencies.4
Summary
4
ACCEPTED MANUSCRIPT
Our patient presented with numerous findings consistent with iatrogenic secondary kwashiorkor, attributable to malabsorption from Roux-en-Y gastric bypass surgery and
RI PT
maladaptive eating behaviors. Longitudinal, multidisciplinary care involving surgeons, internists, and dietitians can provide a supportive environment for those at risk for nutritional
AC C
EP
TE D
M AN U
SC
complications and maladaptive eating behaviors after bariatric surgery.
5
ACCEPTED MANUSCRIPT
References
RI PT
SC M AN U TE D EP
3. 4.
McLaren DS. Skin in protein energy malnutrition. Arch Dermatol. 1987;123(12):1674-1676a. Trehan I, Goldbach HS, LaGrone LN, et al. Antibiotics as part of the management of severe acute malnutrition. N Engl J Med. 2013;368(5):425-435. Srikantia SG, Gopalan C. Role of ferritin in nutritional edema. J Appl Physiol. 1959;14:829-833. Mann D, Presotto C, Queen SM, Oliveira EF, Gripp AC. Cutaneous manifestations of kwashiorkor: a case report of an adult man after abdominal surgery. An Bras Dermatol. 2011;86(6):11741177.
AC C
1. 2.
6
A
ACCEPTED MANUSCRIPT GASTROINTESTINAL BYPASS PROCEDURE Incomplete pancreatic digestion
Degeneration of acinar tissue Fibrosis of the pancreas
Severe hypoproteinemia
RI PT
Steatorrhea
Fatty infiltration of the liver (steatohepatitis)
M AN U
Severe vitamin deficiencies
SC
Dermatoses Anemia Osteoporosis
SECONDARY PROTEIN MALNUTRITION (KWASHIORKOR)
B
TE D
Abnormal Nutritional markers
Normal
1.9 mg/dL Vitamin B1 (3.5-5.2) Ceruloplasmin 9 mg/dL Vitamin B12 (18-53) Vitamin B3
S0002-9343(14)01149-8
DOI:
10.1016/j.amjmed.2014.12.002
Reference:
AJM 12794
To appear in:
The American Journal of Medicine
Received Date: 20 November 2014 Revised Date:
2 December 2014
Accepted Date: 2 December 2014
Please cite this article as: William JH, Tapper EB, Yee EU, Robson SC, Secondary Kwashiorkor: A Rare Complication of Gastric Bypass Surgery, The American Journal of Medicine (2015), doi: 10.1016/ j.amjmed.2014.12.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Title: Secondary Kwashiorkor: A Rare Complication of Gastric Bypass Surgery Authors:
RI PT
Jeffrey H. William, M.D.1 Elliot B. Tapper, M.D. 2 Eric U. Yee, M.D.3 Simon C. Robson, M.B., Ch.B., Ph.D.2 1
Department of Medicine, Division of Nephrology, Beth Israel Deaconess Medical Center Department of Medicine, Division of Gastroenterology, Beth Israel Deaconess Medical Center 3 Department of Pathology, Beth Israel Deaconess Medical Center
Corresponding author: Jeffrey William, MD Beth Israel Deaconess Medical Center 185 Pilgrim Road, Farr 8 Boston, MA 02215 E-mail: [email protected]
M AN U
SC
2
TE D
Funding source(s) related to this manuscript: None
Conflict of interest statement: None of the authors of this manuscript have any potential conflicts of interest, financial, personal, or otherwise.
EP
Author verification: All authors had access to the details of the case and a role in writing the manuscript.
AC C
Classifications: gastroenterology, obesity, nutrition, surgery References: 4 Figures: 1
Word length of abstract: 128 Word length of manuscript: 485 (including references)
1
ACCEPTED MANUSCRIPT
Abstract
RI PT
Bariatric surgery often improves health outcomes for morbidly obese patients and is increasing in popularity. While functional malabsorption is less common with modern surgical techniques, the procedure can still contribute to acquired food intolerance and maladaptive eating
SC
behaviors that can precipitate or worsen pre-existing nutritional deficiencies. When severe, this can lead to protein-energy malnutrition, or kwashiorkor. While more common in resource-poor
M AN U
countries, it is also an under-recognized form of malnutrition in hospitalized patients in Western countries. Herein, we describe a 42-year-old woman status post Roux-en-Y gastric bypass surgery with secondary kwashiorkor, characterized by edema, dermatoses, exocrine pancreatic insufficiency and hepatosteatosis. Longitudinal, multidisciplinary care involving
TE D
surgeons, internists, and dietitians can provide a supportive environment for those at risk for
AC C
EP
nutritional complications after bariatric surgery and subsequent maladaptive eating behaviors.
2
ACCEPTED MANUSCRIPT
To the Editor:
RI PT
Kwashiorkor is a form of severe protein malnutrition that rarely affects adults in developed nations. However, protein-energy malnutrition is likely under-recognized among hospitalized patients in Western countries for whom it is often secondary to non-dietary causes of
SC
malnutrition including malabsorption, chronic alcoholism, kidney disease, severe burns, and
M AN U
bariatric surgery.1
Herein, we describe a 42-year-old woman status post Roux-en-Y gastric bypass surgery with secondary kwashiorkor characterized by edema, dermatoses, exocrine pancreatic insufficiency
Case Report
TE D
and hepatosteatosis (Figure 1, Panel A).
EP
A 42-year-old female with a history of a Roux-en-Y gastric bypass surgery in 2001 was transferred to our hospital with cachexia and anasarca. Her post-operative course had been
AC C
marked by early satiety and poor nutritional intake over the next 10 years. Months prior to admission, she developed malodorous stools along with an enlarging abdomen followed by anasarca with weeping blisters and erythema. Physical exam found temporal wasting, scleral icterus, angular cheilosis, with thinning and depigmented hair. The skin over her body was free of spider angiomata and palmar erythema, but her fingertips were peeling with a purple discoloration. The abdomen was distended with shifting dullness, but without caput medusae. 3
ACCEPTED MANUSCRIPT
Laboratory studies were as shown in Figure 1, Panel B. Endoscopy revealed duodenal villous blunting. Percutaneous liver biopsy demonstrated severe hepatosteatosis and inflammation
RI PT
without Mallory hyaline inclusions, consistent with non-alcoholic steatohepatitis given her lack of alcohol intake and strong collateral history.
SC
Discussion
Secondary kwashiorkor after bariatric surgery may be an under-recognized etiology of
M AN U
malnutrition, which can develop following self-prescribed modifications in diet to achieve greater weight loss by substituting whole foods and protein with carbohydrate-rich, highcalorie alternatives. Kwashiorkor has numerous entities demonstrated by our patient, including: (1) hepatosteatosis secondary to decreased hepatic synthesis of plasma beta-
TE D
lipoproteins and intestinal epithelial-barrier dysfunction leading to hepatic necroinflammation,2 (2) exocrine pancreatic insufficiency due to the high rate of protein turnover, (3) edema secondary to ineffective hepatic inactivation of ADH and ferritin release from damaged
EP
hepatocytes promoting further increased ADH secretion and hyperaldosteronism,3 and (4) dermatoses, represented by changes in hair characteristics (depigmented and brittle) along
AC C
with a multitude of skin findings from an array of combinations of vitamin and micronutrient deficiencies.4
Summary
4
ACCEPTED MANUSCRIPT
Our patient presented with numerous findings consistent with iatrogenic secondary kwashiorkor, attributable to malabsorption from Roux-en-Y gastric bypass surgery and
RI PT
maladaptive eating behaviors. Longitudinal, multidisciplinary care involving surgeons, internists, and dietitians can provide a supportive environment for those at risk for nutritional
AC C
EP
TE D
M AN U
SC
complications and maladaptive eating behaviors after bariatric surgery.
5
ACCEPTED MANUSCRIPT
References
RI PT
SC M AN U TE D EP
3. 4.
McLaren DS. Skin in protein energy malnutrition. Arch Dermatol. 1987;123(12):1674-1676a. Trehan I, Goldbach HS, LaGrone LN, et al. Antibiotics as part of the management of severe acute malnutrition. N Engl J Med. 2013;368(5):425-435. Srikantia SG, Gopalan C. Role of ferritin in nutritional edema. J Appl Physiol. 1959;14:829-833. Mann D, Presotto C, Queen SM, Oliveira EF, Gripp AC. Cutaneous manifestations of kwashiorkor: a case report of an adult man after abdominal surgery. An Bras Dermatol. 2011;86(6):11741177.
AC C
1. 2.
6
A
ACCEPTED MANUSCRIPT GASTROINTESTINAL BYPASS PROCEDURE Incomplete pancreatic digestion
Degeneration of acinar tissue Fibrosis of the pancreas
Severe hypoproteinemia
RI PT
Steatorrhea
Fatty infiltration of the liver (steatohepatitis)
M AN U
Severe vitamin deficiencies
SC
Dermatoses Anemia Osteoporosis
SECONDARY PROTEIN MALNUTRITION (KWASHIORKOR)
B
TE D
Abnormal Nutritional markers
Normal
1.9 mg/dL Vitamin B1 (3.5-5.2) Ceruloplasmin 9 mg/dL Vitamin B12 (18-53) Vitamin B3
