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Home , Thiamine, Thiamine deficiency

Double Trouble After Sleeve Gastrectomy Ashray Maniar, MD; Deanna Green, MD; Alan J. Hunter, MD Department of Medicine, Oregon Health & Science University

Introduction Physiology and Pathophysiology Central vs Peripheral Vertigo Micronutrient deficiencies are a known Thiamine function Risk Factors for Cellular consequence of Fixed direction Multidirectional complication of . This dysarthria, Day 1 Deficiency deficiency - No suppression - Suppression case illustrates in a use, with gaze fixation with gaze fixation post-bariatric surgery patient, and advanced age, - Associated - Associated bariatric surgery, highlights the importance of close post- brainstem or hearing loss, obesity, HIV/AIDS, cerebellar prominent nausea operative monitoring, educating patients long term use of high on bariatric diet and recognizing key dose features of various nutritional Central Vertigo Peripheral Vertigo deficiencies Hypometabolism, BPPV, vestibular CVD, seizure, MS, neuritis, Day 3 hypoperfusion, Meniere’s, neoplasia, toxins acoustic neuroma, drugs, perilymphatic Case Presentation Outcomes Radiographic Features Clinical Symptoms fistula Responds A 23-year-old woman 2 months status well to Mechanical Complications of post sleeve gastrectomy in Saudi Arabia repletion and presents with acute diplopia, gait correction of Bariatric Surgery underlying instability in setting of persistent post- issue. operative nausea, vomiting and poor oral Untreated Complication Etiology Symptoms Treatment intake, resulting in the inability to take can lead to Dumping • Pyloric sphincter Early • Avoid rapid coma or syndrome incompetence • hyperosmolar absorbed her supplemental A encephalopathy • vagus gradient  carbs and death MRI showing increased T2 FLAIR intensity at insufficiency , lactose mammillary bodies bloating, • Acarbose Seen in both restrictive vasomotor sx • somatostatin Physical exam and malabsorptive Late analogues surgery • hypoglycemia • Bidirectional horizontal nystagmus L Thiamine Deficiency > R, diplopia, gait imbalance GERD Multifactorial, more Chest , Dietary common in restrictive burning sensation, modifications, • Thiamine deficiency manifests as wet or dry Beriberi, Wernicke- metallic test, behavioral , and optic neuropathy cough, sleeping modifications, Lab results disturbances PPIs 138 100 2 12 • Beriberi is a Sinhalese phrase meaning “weak, weak” or “I 92 8.0 235 cannot, I cannot” 2.7 23 0.3 36.0 • The Classic triad of Wernicke’s is only present in 10-16% of cases • Ocular dysfunction most commonly horizontal nystagmus > Key Points +2 +2 lateral gaze palsy > conjugate gaze palsy >>> complete Ca 9.4 Mg 2.1 PO4 2.7 • As the frequency of bariatric surgery ophthalmoplegia or pupillary defects Alb 3.2 Normal liver panel increases, post-operative complications • Initial treatment should be with high dose intravenous thiamine for will become more ubiquitous at least 3 days • CT head and MRI brain without • Bariatric surgeries carry a significant • Dose recommendations vary from 100-500 mg IV daily to abnormality risk for multiple micronutrient multiple doses. Once resolved, should maintain daily 100 mg oral • CT abdomen: chronic fluid deficiencies that are preventable with supplement collection adjacent to stomach, dietary education and without evidence of infection Micronutrient deficiencies following Bariatric Surgery supplementation • Recognizing clinical features of multiple Outcome Vitamin (Frequency) Manifestation Treatment micronutrient deficiencies can lead ot Thiamine (***0-30%) Within days-months: AMS, neuropathy, Vitamin B1 100-500 mg IV TID  • Empirically treated with high dose (emesis is a key predisposing nystagmus, ocular palsy PO thiamine prompt diagnosis and treatment IV thiamine 500 mg TID factor) • Thiamine deficiency is seen in both • Symptoms improved within 12 Seen in both restrictive and restrictive and malabsorptive surgeries, hours of thiamine administration malabsorptive surgery can be fatal if not rapidly treated B12 (0-18%) Occurs over months-years: 1000 ug IM x 8 weeks (daily –> life • Further labs: Anemia, myelopathy, neuropathy long if neurologic sx) o Thiamine: 42 nmol/L (70-180), (very rare) Anemia, risk for NT defects 5 mg daily References o : 4.9 nmol/L (20-125) (25-75%) Occurs over months-years: Bone loss, 50,000 IU D2 x 8 weeks o , hypocalcemia symptoms 1. Karatas, Mehmet. "Central vertigo and dizziness: epidemiology, differential : 0.14 mg/L (0.3-1.2) diagnosis, and common causes." The neurologist 14.6 (2008): 355-364. 2. Kerns, Jennifer C, et al. “Thiamine deficiency in people with Obesity.” o Normal , Cu, Ferritin, Advances in Nutrition, 6.2 (2015): 147-153. Vitamin A (0-11%) Occurs over months-years: 10,000-25,000 IU until improvement 3. Katta, N et al. “Does long-term therapy cause thiamine deficiency and Zinc Dry eyes, reduced night vision in patients with failure? A focused review.” American Journal of Medicine 129.7 (2016): 753.e7-753.e11. • Symptoms resolved by day 3, Zinc (6%) Occurs over months-years 60 mg (may deplete Cu stores) 4. Zuccoli, G1, et al. "MR imaging findings in 56 patients with Wernicke Poor wound healing encephalopathy: nonalcoholics may differ from alcoholics." American Journal of transitioned to oral thiamine, Neuroradiology 30.1 (2009): 171-176. Copper (~10%) Anemia, leukopenia, neuropathy, 6 mg daily x74 mg qD x 7 2 mg 5. Aasheim, Erlend Tuseth. " after bariatric surgery: a educated on adherence to systematic review." Annals of surgery 248.5 (2008): 714-720. myelopathy, ataxia 6. Alvarez-Leite, Jacqueline I. " deficiencies secondary to bariatric surgery." regimen, bariatric diet Current Opinion in Clinical Nutrition & Metabolic Care 7.5 (2004): 569-575. Vitamin E Mimics B12 without anemia and discharged with follow-up with D-lactate acidosis Anion gap metabolic acidosis + altered NPO, provide IV nutrition  long nutrition and bariatric surgery sensorium (Risks: short gut syndrome) term carbohydrate restriction; Abx