About the case study
This is a real case report of a lady who had undergone bariatric surgery and developed complications associated with nutrient deficiencies 10-12 years later. In this case study, we will examine the patient's experience until she started taking multivitamins, and then how her journey took a U-turn when she stopped taking them and began facing health challenges.
About the lady:
The woman was 42 years old when she underwent bariatric surgery in 2001. She underwent Biliopancreatic diversion (BPD, a mixed bariatric surgery technique, both restrictive and malabsorptive) in 2001.
Before surgery, her weight and body mass index (BMI) were 132.5 kilograms and 48.7 Kg/m2, respectively (body weight excess of 64 Kg).
Journey after bariatric surgery: Post-Surgery Nutritional Challenges
She took regular follow-ups. She was taking a vitamin supplement for 7 years. In 2008, she missed the follow-up. Due to economic challenges and work-related problems, she was not taking supplements as well.
Finally, 10 years after surgery, she visited the clinic for follow-up.
What happened in 10 years?
She had deficiencies of vitamin A, vitamin D, zinc, copper, and iron. Serum gamma-glutamyl transpeptidase was also elevated.
Her treatment started with zinc sulphate (15 mg/day of elemental zinc), ferrous sulphate (40 mg/day), calcium carbonate ((5,000 mg/day) and cholecalciferol (1760 IU/day), calcifediol (798 mcg/week), vitamin A (retinyl palmitate 50,000 IU daily), vitamin E (α-tocopherol acetate 200 mg/day), cyanocobalamin (1000 mcg/month) and two multivitamin supplements with minerals and trace elements.
She was detailed about diet, and oral intake was reinforced.
Challenges after initial treatment: What happened after 12 years?
One year later (150 months), she experienced protein malnutrition with other health challenges (oedema, dermatitis). Serum analysis showed zinc deficiency and anaemia. Treatment was started with oral nutritional supplements and corticosteroids.
Twelve weeks later (153 months, 12 years after surgery), she consulted an endocrinologist for a skin lesion (one-year history of progressive dermatitis).
Her symptoms included blister-like lesions, chronic diarrhoea, tiredness, difficulty walking, edema, etc.
At this stage, she was taking only iron, vitamin B12 injections, and multivitamins, but had stopped taking calcium, zinc, and vitamins A, E, and D, which contributed to worsening nutritional deficiencies.
Insisting on the importance of adherence to diet and vitamin supplements, treatment with zinc sulphate (30 mg/day), vitamin A (50,000 IU daily), calcifediol (798 mcg/week) and vitamin E (200 mg/day) was prescribed.
2 days after this, she was diagnosed with severe protein-energy malnutrition and extensive dermatitis. At this point, she was diagnosed with multiple nutrient deficiencies, anemia and bacterial overgrowth. She was managed with multiple nutrients administered via different routes (such as intravenous zinc and intramuscular thiamine), enzyme supplements, and a multivitamin supplement containing minerals and trace elements.
She was instructed to start with a bland, simple diet with an additional oligomonomeric, peptidic, glutamine-enriched, high-protein oral supplement.
How her journey started improving
After the aforementioned nutrient supplement strategies, improvements were noted in the following:
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Skin lesions started improving
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Gut health started improving
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Nutritional parameters improved
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Complete resolution of dermatitis
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Body weight at discharge was 74 Kg, with a BMI of 27.5 kg/m2
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normal laboratory values.
What was recommended?
She was instructed to take oral nutritional supplement, two multivitamin complexes, ferrous sulphate (40 mg/day), cyanocobalamin (1000 mcg IM/month), zinc sulphate (30 mg/day), vitamin A (50000 IU daily), calcifediol (798 mcg/week) and vitamin E (200 mg/day).
She was recalled for follow-up after 1 month and 3 months.
How has she changed?
She demonstrated compliance with treatment.
She moved to another city but continued to take supplements and follow up.
Important findings from the case
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Protein malnutrition is a complication of bariatric surgery.
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Iron and zinc deficiency is common in these patients.
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Zinc deficiency is characterised by dermatitis, diarrhea and alopecia. Skin lesions are early signs.
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When patient stopped the multivitamin, significant vitamin and trace elements deficiencies appear.
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Lifelong monitoring following bariatric surgery is important to ensure that nutritional requirements are met.
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Lifetime supplementation is also important to reduce post‐bariatric surgery–related nutritional deficiencies and complications.
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Close follow-up is recommended during the first two years, and then it should be performed annually.
Lessons From This Case
This case highlights the serious long-term nutritional risks associated with bariatric procedures, particularly when patients discontinue supplementation or follow-up care.
Reference:
Herrera-Martínez AD, Junquera-Bañares S, Turrión-Merino L, Arrieta-Blanco F, Botella-Carretero J, Vázquez-Martínez C and Calañas-Continente A (2021) Case Report: Extensive Dermatitis Secondary to Severe Malnutrition, Zinc and Vitamin Deficiencies After Malabsorptive Bariatric Surgery. Front. Endocrinol. 12:623543. doi: 10.3389/fendo.2021.623543
