Case Report

Gregory B. Dodell, MD1; Jeanine B. Albu, MD1; Lawrence Attia, MD2;

James McGinty, MD3; F. Xavier Pi-Sunyer, MD1; Blandine Laferrère, MD1

ABSTRACT Regardless, in addition to the altered anatomy after bariat-

ric surgery, the further insult of IBD poses a severe threat
Objective: To describe the potential long-term risk to the nutritional status of affected patients. Malnutrition
of malnutrition after Roux-en-Y gastric bypass (GBP) needs to be recognized and aggressively treated. Nutritional
through an uncommon occurrence of inflammatory bowel markers should be followed closely in this population of
disease (IBD) postoperatively, which posed a serious threat bariatric patients in an effort to avert the onset of severe
to the nutritional status and the life of the patient. malnutrition. (Endocr Pract. 2012;18:e21-e25)
Methods: We present a case report of a 44-year-old
woman in whom Crohn disease developed 4 years after she Abbreviations:
had undergone GBP. The double insult of IBD and GBP BMI = body mass index; GBP = gastric bypass; IBD
resulted in severe malnutrition, with a serum albumin con- = inflammatory bowel disease; TPN = total parenteral
centration of 0.9 g/dL (reference range, 3.5 to 5.0), weight nutrition
loss, and watery diarrhea necessitating 6 hospital admis-
sions during a period of 7 months.
Results: Ultimately, the administration of total paren- INTRODUCTION
teral nutrition with aggressive macronutrient, vitamin, and
mineral repletion resulted in substantial improvement in Bariatric surgery for morbid obesity leads to substan-
the patient’s strength, function, and quality of life, in paral- tial and sustained weight loss in conjunction with impres-
lel with diminished symptoms of IBD. sive improvement in diabetes mellitus, blood pressure, and
Conclusion: Rarely, IBD develops after GBP, but the lipid profiles (1). In 2008, the number of bariatric surgi-
relationship between the 2 conditions remains unclear. cal procedures performed in North America was 220,000
(2), and the frequency of performance of such operations
is predicted to increase. In response to the recognized need
for effective nutritional follow-up in these patients after
gastric bypass (GBP), clinical practice guidelines have
recently been published (3,4).
Because of the duodenal bypass and an anastomosis
far down into the jejunum, malabsorption occurs, and these
patients are at risk for long-term complications (5). Protein
malnutrition, defined as a serum albumin level <3.5 g/dL,
Submitted for publication July 11, 2011 remains the most severe macronutrient complication asso-
Accepted for publication October 17, 2011
ciated with malabsorptive surgical procedures. Intolerance
From the 1Division of Endocrinology, Diabetes and Nutrition, 2Division
of Gastroenterology, and 3Department of Surgery, St. Luke’s Roosevelt of protein-rich foods is common postoperatively; therefore,
Hospital Center, New York, New York. many patients do not meet their recommended daily intake
Address correspondence to Dr. Gregory B. Dodell, Division of
of protein (6). In addition, malabsorption contributes to the
Endocrinology, Diabetes and Nutrition, St. Luke’s Roosevelt Hospital
Center, 1111 Amsterdam Avenue, 10th Floor, New York, NY 10025. E-mail: total reduction in protein absorption after bariatric surgery
[email protected]. (7). Protein malnutrition causes an annual hospitalization
Published as a Rapid Electronic Article in Press at http://www.endocrine
rate of 1% per year after malabsorptive procedures and
practice.org on December 2, 2011. DOI:10.4158/EP11200.CR
To purchase reprints of this article, please visit: www.aace.com/reprints. leads to considerable morbidity (8). After GBP, supplemen-
Copyright © 2012 AACE. tation of vitamins and minerals to overcome deficiencies is

ENDOCRINE PRACTICE Vol 18 No. 2 March/April 2012 e21

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also necessary because of the increased risk imposed by serum albumin concentration was above 4 g/dL (reference
anatomic changes (9). range, 3.5 to 5.0) at 4 years postoperatively.
The further insult of inflammatory bowel disease At 4 years after GBP, however, the patient developed
(IBD) to the remaining intact intestine of a patient after 1 to 2 episodes per day of watery diarrhea. A colonoscopy
GBP can result in a life-threatening situation, as demon- biopsy demonstrated moderate chronic active colitis with
strated in the following case. In light of the increased sus- focal cryptitis, consistent with Crohn disease, and treatment
ceptibility for malnutrition after GBP, irrespective of IBD, with mesalamine (800 mg 3 times a day) was initiated. The
this double insult necessitates intensive nutritional evalua- patient had lost an additional 9 kg from her plateau weight
tion and treatment. after GBP to a weight of 81 kg. A repeated colonoscopy
8 months later showed a good response to treatment with
CASE PRESENTATION mildly diminished inflammation.
Several months later, however, the patient had a
A 44-year-old woman developed IBD 4 years after relapse with diarrhea and abdominal pain. She had lost
Roux-en-Y GBP. Before bariatric surgery, she was severely an additional 11 kg to a weight of 70 kg, and a repeated
obese, with a body mass index (BMI) of 38.5 kg/m2, and colonoscopy revealed worsening diffuse active colitis from
she had hypertension, hyperlipidemia, depression, and gas- the sigmoid colon to the hepatic flexure. Despite continued
troesophageal reflux disease. Immediately postoperatively, treatment of the colitis, the diarrhea persisted, and weight
all her medications for comorbidities were discontinued. loss continued to 65 kg. The patient had 6 hospital admis-
By 7 months after GBP, she had lost 28 kg. During the first sions during a period of 7 months, for a total of 74 days in
postoperative year, the patient was under close follow-up the hospital. The Endocrinology Service was consulted for
surveillance by the bariatric surgeon. The institution’s regi- nutritional management.
men consisted of visits at 1 week, 1 month, and then every On the initial evaluation, the patient was cachectic
3 months for 2 years, followed by annual visits. with a BMI of 21.2 kg/m2, and 3+ bilateral pitting edema
The patient saw her primary physician annually for 3 of the lower extremities was present. She required assis-
years postoperatively but was then lost to follow-up. At 3 tance for ambulation and had decreased grip strength. Her
years, her weight was stable at 90 kg. She continued to take serum prealbumin level was 5.2 mg/dL (reference range,
a multivitamin, calcium citrate (600 mg) plus vitamin D 20 to 40), and anemia and other severe vitamin and mineral
(400 U) twice daily, and ferrous sulfate (325 mg daily). Her deficiencies were present (Table 1).

Table 1
Vitamin and Mineral Supplementation Trend in Study Patient

At hospital At
discharge 14 days
Reference Initial (after 14 days after
Analyte range consultation Supplement of TPN) Supplement discharge

Prealbumin (mg/dL) 20-40 5.2 TPN 19.9 TPN/PO 30

Albumin (g/dL) 3.5-5.0 0.9 TPN 2.6 TPN/PO 3.6

Vitamin A (mg/L) 0.3-1.2 0.06 50,000 U IM × 2 0.26 … …

25-Hydroxyvitamin D (ng/mL) 30-80 14 Vitamin D2, 37 Vitamin D3, 34

50,000 U × 3; 2,000 U daily
vitamin D3,
5,000 U daily

Vitamin E (mg/L) 5.5-18 6 TPN/multivitamin 10.5 … …

Iron (µg/dL) 37-170 34 Ferrlecit, 125 mg 29 Ferrous sulfate, 49

Ferritin (ng/mL) 10-291 144 IV × 2; ferrous 325 mg BID
gluconate, 325
mg daily

Vitamin B1 (nmol/L) 8-30 5 100 mg IV daily 22 Multivitamin …

Vitamin B12 (pg/mL) 211-911 718 Multivitamin/TPN 848 2,000 mg PO daily 1,233

Abbreviations: BID = twice daily; IM = intramuscularly; IV = intravenously; PO = orally; TPN = total parenteral nutrition.
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The diagnosis of severe protein malnutrition was she continued progression toward her previous function
made, and treatment with total parenteral nutrition (TPN) and quality of life. A dual-energy x-ray absorptiometry
was initiated because malabsorption was suspected on the scan was done, which demonstrated normal bone density.
basis of the patient’s continuous diarrhea with oral intake.
In addition to TPN, elemental oral feedings (Vital 1.0) DISCUSSION
were given but ultimately had to be discontinued because
of increased frequency of diarrhea. The daily TPN was This 44-year-old woman, who underwent GBP for
titrated up to 1,949 kcal daily during 2 weeks of treat- treatment of severe obesity and metabolic syndrome, sub-
ment. Supplementation with both intravenously and orally sequently developed severe malnutrition in conjunction
administered vitamins and minerals was initiated (Table with Crohn disease 4 years after bariatric surgery. A few
1). Throughout the hospitalization, the improvement in reported cases have described Crohn disease associated
clinical and nutritional status was dramatic. The patient’s with GBP and severe malnutrition that improved with stan-
strength improved to the point of independent ambulation, dard therapy for IBD (10). The current case, as the others
her edema resolved, and the diarrhea decreased. previously reported, raises the question of a possible asso-
At the time of hospital discharge, the patient was toler- ciation between GBP and IBD.
ating small meals and snacks. Medications included mesal- Investigators have speculated that, just as bacterial
amine (800 mg 3 times a day), prednisone (20 mg daily), overgrowth can occur after gastrectomy, the altered anat-
vitamin B12 (2,000 mg daily), vitamin D3 (2,000 U daily), omy after GBP may promote a bacterial milieu in geneti-
calcium carbonate (500 mg)-vitamin D3 (200 U) twice cally predisposed patients that triggers chronic inflamma-
daily, ferrous sulfate (325 mg twice a day), and a multi- tion and results in Crohn disease (11). The double insult of
vitamin. Overnight TPN was continued as an outpatient GBP and IBD on the functioning bowel can clearly have a
treatment for a period of 2 weeks and then was discontin- dramatic effect on a patient’s nutritional health and func-
ued when the prealbumin level was 30 mg/dL (reference tional well-being.
range, 20 to 40). Bowel movements were firm, 1 to 2 times Malnutrition is a common feature of Crohn disease.
daily, and the patient continued to tolerate oral intake. Her The cause is multifactorial; postprandial pain, diarrhea, and
weight at that time was 69 kg, with a total weight regain malabsorption can be contributing factors (12). Vitamin
of 14 kg since admission (see Figure 1 for weight trend). deficiencies have been reported both in Crohn disease and
Strength improved with outpatient physical therapy, and after GBP (13,14). In the current patient, because of poor

Fig. 1. Body weight changes of study patient. First arrow indicates time of gastric bypass. Second
arrow indicates time of diagnosis of Crohn disease. Third arrow indicates time of nutritional
intervention.
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follow-up after GBP, it is unclear whether she was mal- and may be advanced with the presence of another gut
nourished before the development of Crohn disease. injury such as Crohn disease. Accordingly, physicians must
To our knowledge, only 3 cases of IBD after GBP have have a heightened awareness of this possibility to avoid
been reported (10). All were in women, 28 to 46 years old, life-threatening consequences in bariatric patients. When
who had undergone GBP from 11 months to 5 years before malnutrition is established and not easily corrected, a mul-
the development of IBD, with BMIs ranging from 43 to tidisciplinary team approach emphasizing aggressive nutri-
75 kg/m2 at the time of diagnosis of Crohn disease. The tion assessment and restoration, including TPN, should be
initial manifestations were abdominal pain and weight loss used early on to manage such patients.
(up to 9 kg), and none of the patients had a family his-
tory of IBD. With treatment of the Crohn disease, diarrhea DISCLOSURE
resolved and weight loss subsided. Although our currently The authors have no multiplicity of interest to disclose.
described patient had a similar age and had no family his-
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