CME Topic Vitamin Deficiency After Gastric Bypass Surgery: A Review Marc R. Matrana, MD, MS, and William E. Davis, MD tract to achieve weight loss by gastric restriction and intesti- Abstract: More than 60% of the adult US population now meets the nal malabsorption.4,5 Typically, a long-term loss of one third criteria for being overweight or obese. Gastric bypass surgery has of body weight and resolution of many comorbid conditions become a popular and effective way to combat this medical problem. are achieved.6 Despite successes, these procedures have mul- Despite the success of these procedures, they are associated with tiple inherent risks and complications, including malnutrition, many complications, including malnutrition, neurological compro- neurological compromise, and vitamin deficiency.7–9 mise, and vitamin deficiency. Research has determined that even A 37-year-old female with morbid obesity underwent with multivitamin supplementation for life, a large percentage of RYGBP 3 months prior to presentation. Her operation was un- bypass patients develop vitamin deficiencies. We present a case complicated, but she received no follow-up care. Two weeks of beriberi after Roux-en-Y bypass that illustrates the importance of prior to presentation, the patient developed mild paresthesia of close follow up. A thorough review of vitamin deficiencies in this the anterior right leg. Two days prior to presentation, her pares- unique patient population is explored. Vitamin supplementation and thesia worsened and began to involve the left leg as well. She treatment recommendations are compiled from the most up-to-date also noted progressive weakness of the lower extremities bilat- sources. Even patients on regular supplements should be closely erally. One day later, she experienced acute problems walking, monitored for vitamin deficiencies. Patient education regarding vi- fell down after her knees buckled under her weight, and was tamin supplementation is vital; it should begin prior to surgery and unable to stand due to weakness. She noted persistent nausea continue throughout the postoperative period and beyond. and vomiting and a 60-pound weight loss since her surgery. Key Words: bariatric surgery, gastric bypass surgery, nutritional On admission, bilateral lower extremity proximal muscle supplementation complications, vitamin deficiency weakness was noted from the thighs distally. Bilaterally de- creased sensation to light touch from the knees distally was noted, and reflexes were diminished. Neurological examina- besity has reached epidemic levels, and its incidence tion revealed intact cranial nerves and no upper extremity Ocontinues to rise. More than 60% of the adult US pop- abnormalities. There were no signs of cardiac disease. A com- ulation now meets the criteria for being overweight or obese.1 puted tomography scan of the head, and magnetic resonance Bariatric surgery has become a popular and effective way to imaging of the brain and spine, showed no abnormalities. combat this medical problem, with more than 100,000 pro- Complete blood count, comprehensive metabolic profile, sed- cedures performed annually.2 It is estimated that over the next imentation rate, and C-reactive protein levels were unremark- few years the total number of obesity surgery patients in the United States will exceed 1 million.3 Gastric bypass surgeries, such as Roux-en-Y (RYGBP) and biliopancreatic diversion, reconfigure the gastrointestinal Key Points • Gastric bypass surgery is associated with serious vi- tamin deficiencies. From the Internal Medicine Residency Program, and Department of Rheu- • Primary care physicians and others should be diligent matology, Ochsner Clinic Foundation, New Orleans, LA. in vitamin supplementation and treatment in this pop- Reprint requests to William E. Davis, MD, Ochsner Clinic Foundation, 1514 ulation to prevent serious complications. Jefferson Highway, New Orleans, LA 70121. Email: wdavis@ • Vitamin supplementation should be continued for life, ochsner.org and even patients on regular supplements should be The research reported here was conducted using only departmental support. closely monitored for vitamin deficiencies. Dr. Marc Matrana has no conflicts of interest to report and no financial disclosures to declare. Dr. William Davis has received honoraria from • Patient education is paramount, and emphasis regard- Wyeth as a consultant and from Takeda as a speaker. ing the importance of vitamin and other nutrient sup- Accepted March 13, 2009. plementation should begin prior to surgery and con- Copyright © 2009 by The Southern Medical Association tinue throughout the postoperative period and beyond. 0038-4348/0Ϫ2000/10200-1025 Southern Medical Journal • Volume 102, Number 10, October 2009 1025 Matrana and Davis • Vitamin Deficiency After Gastric Bypass Surgery able. Vitamin levels revealed undetectable thiamine levels tional deficiencies. Deficiencies also develop secondary to (Ͻ0.5 nmol/L). B12 and other vitamin and mineral levels the loss of gastrointestinal segments where nutrients are ab- were normal. sorbed. Vitamin deficiencies are among the more common Aggressive thiamine replacement was started immedi- nutritional problems in bariatric surgery patients, and they ately, with 100 mg of intravenous (IV) thiamine followed by present in a variety of ways. Inadequate vitamin levels lead to 100 mg of intramuscular thiamine daily. After three days, the serious neurological, hematological, and other manifestations. patient showed little improvement and was still unable to No firm guidelines for vitamin supplementation exist in this walk. Physical therapy was initiated, and the patient was patient group, and data are relatively scarce. Research has transported to our rehabilitation facility, where she received found wide variations in vitamin supplementation and mon- daily physical therapy and oral thiamine replacement. After itoring among surgeons who treat postgastric bypass patients three weeks, she had slowly but progressively improved and (Table).11 was able to ambulate 150 feet with a rolling walker. The average patient maintains food consumption between Vitamin A 600 and 900 kcal daily after gastric bypass surgery.10 Without Vitamin A refers collectively to a number of retinoids supplementation, such dietary restriction often leads to nutri- that are essential for visual acuity, immunological func- Table. Summary of vitamin supplementation recommendations for postgastric bypass patients Recommended daily Recommended daily oral Major natural dietary Deficiency-associated allowance (RDA) in supplementation in sources symptoms healthy adults gastric bypass patients Vitamin A Liver, leafy green vegetables, Night blindness, xerosis, Adult male: 900 ␮g/d. Adult 10,000 IU/d14 (approx 3,000 carrots, sweet potatoes, and impaired immunity, and female: 700 ␮g/d ␮g/d)a pumpkins changes in epithelial tissues and teeth Vitamin B1 Fortified breads, cereals, Wernicke encephalopathy, Adult male: 1.2 mg/d. Adult 50–100 mg/db (thiamine) pastas, whole grains, dried Korsakoff syndrome, and female: 1.1 mg/d beans, peas, and soy beriberi Vitamin B9 Liver, leafy green vegetables, Macrocytic megaloblastic Adults: 400 ␮g 0.5–1 mg/d (folate) dried beans, and cereals anemia, diarrhea, anorexia, weight loss, weakness, headaches, and behavior changes Vitamin B12 Meat, milk, shellfish, and Macrocytic megaloblastic Adults: 2.4 ␮g/d 350–500 ␮g/d (some patients (cobalamin) eggs anemia, peripheral nerve may require monthly damage, coordination intramuscular B12 injections disorders, ataxia, and of 1,000–3,000 ␮g/dose) cognitive impairments Vitamin C Citrus fruits, green peppers, Scurvy (bleeding and Adult male, nonsmoker: 90 mg/d. No clear consensus. Patients (ascorbic acid) strawberries, tomatoes, bruising, hair and tooth Adult male, smoker: 125 mg/d. should consume foods and broccoli, leafy greens, and loss, and joint pain and Adult female, nonsmoker: 75 supplements rich in vitamin C melons swelling) mg/d. Adult female, smoker: 110 mg/d Vitamin D Some fatty fish (mackerel, Increased incidence of certain Adults ages 19–50: 5 ␮g/d. 800–1,200 IU/d (20–30 ␮g/d) salmon, and sardines), fish cancers, heart disease, and Adults ages 51–70: 10 ␮g/d. along with at least liver oils, and eggs, as well osteoporosis Adults ages Ն71: 15 ␮g/dc 1,200–1,800 mg/d of calcium as fortified milk, formula, citrate orange juice, and cereals Vitamin E Avocados, nuts and seeds, Ataxia, peripheral neuropathy, Adults: 15 mg/d Supplement with standard olives, green leafy myopathy, and pigmented multivitamin formulation rich vegetables, and vegetable retinopathy in vitamin E oils Vitamin K Green leafy vegetables and in Stomach pains, bleeding, Adult male: 120 ␮g/d. Adult At least 300 ␮g/d some vegetable oils, cartilage calcification, female: 90 ␮g/dc including soybean, malformation of developing cottonseed, canola, and bone, and atherosclerosis olive oils aThe exact conversion between international units and micrograms is dependent on the source of vitamin A. bRepresents standard maintenance dose in patients who have been treated for thiamine deficiency or beriberi. cRDA has not been established. Recommendations based on Institute of Medicine’s Adequate Intake (AI) levels. 1026 © 2009 Southern Medical Association CME Topic tioning, and cell proliferation and differentiation. Retin- RDA of 1.2 mg for men and 1.1 mg for women is normally oids also function to protect tissues from oxidative stress exceeded in the average American diet.21 caused by free radicals. Found