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Unintended consequences of bariatric surgery the changing face of a familiar disease

Learning Objectives. Impact of bariatric surgery on nutritional deficienciesNeurologic complications after bariatric surgery. Course of illness in 26 year old Caucasian Female . . progressive bilateral lower extremity weakness inability to walk Blurred and double vision Mental sluggishness pe

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Unintended consequences of bariatric surgery the changing face of a familiar disease

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    1. Unintended consequences of bariatric surgery – the changing face of a familiar disease Andrea Braun MD Thomas S. Huddle MD Division of General Internal Medicine

    2. Learning Objectives Impact of bariatric surgery on nutritional deficiencies Neurologic complications after bariatric surgery

    3. Course of illness in 26 year old Caucasian Female

    4. Other Pertinent History PMH: morbid obesity asthma hypertension depression, anxiety Medications: Paroxetine, Quetiapine, Alprazolam Fosinopril PRN albuterol and atrovent inhalers Social History: No tobacco, alcohol or drugs Family History: noncontributory

    5. Physical Exam VS: BP 146/98 HR 111 RR 22 T 99.1şF Obese Caucasian female with flat affect, tearful Neurological exam: Unable to walk; 2/5 strength and areflexia in both lower extremities bilateral ophthalmoplegia Spontaneous horizontal nystagmus Normal upper extremity strength and reflexes Normal sensory exam Normal rectal sphincter tone

    6. Diagnostic considerations Neuromuscular disorder Myopathy / Myositis Myelopathy Neuropathy Multiple sclerosis Guillain-Barre Syndrome Conversion disorder Vitamin or nutritional deficiency

    7. Diagnostic Evaluation

    8. Evaluation of metabolic and nutritional deficiencies

    9. Clinical Diagnosis Wernicke’s Encephalopathy secondary to thiamine deficiency

    10. Hospital Course and Follow-Up Initiation of daily IV thiamine and multivitamin therapy gradual improvement over several months Complete resolution of ophthalmoplegia and nystagmus Partial improvement in bilateral lower extremity weakness

    11. Wernicke’s Encephalopathy Historically most commonly observed in alcoholism Classical Triad (seen in only 16%): ocular changes (ophthalmoplegia, nystagmus) ataxia encephalopathy / mental status changes

    12. Epidemiology Prevalence in autopsy series: 0.8–2.8% Male : Female Ratio = 1.7 : 1 Mortality: 17% Diagnosis missed in 75-80% of autopsy-confirmed cases in alcoholics or AIDS patients 80% of survivors develop Korsakoff Syndrome

    14. Clinical settings Chronic alcohol abuse and malnutrition Unbalanced nutrition (e.g. polished rice) Gastrointestinal surgical procedures Recurrent vomiting and diarrhea Cancer Systemic diseases: Renal disease AIDS Thyrotoxicosis Chronic infectious diseases

    15. Prevention and Treatment of Wernicke’s Encephalopathy Recommended daily dose of thiamine in healthy adults: 1.4 mg/day Requirements are higher in children, critical illness, pregnancy, lactation Treatment dose: 100mg thiamine IV

    16. Thiamine deficiency after gastric bypass surgery 18.3 % incidence of thiamine deficiency one year after gastric bypass surgery 0.4% of all patients developed Wernicke’s encephalopathy 28% of patients with neurologic complications after bariatric surgery suffer from Wernicke’s encephalopathy or Wernicke-Korsakoff syndrome

    17. Summary

    18. References Incidence of Vitamin Deficiency after laparoscopic Roux-en-Y Gastric Bypass in a University Hospital Setting. Clements R et al. Am Surg 72:1196-1204; 2006 Neurologic complications after surgery for obesity. Koffman B et al. Muscle & Nerve 33:166-176; 2006 Nutritional and metabolic complications of bariatric surgery. Malinowski S. Am J Med Sci 331(4):219-225; 2006 Nutrient deficiencies secondary to bariatric surgery. Alvarez-Leite J. Curr Op Clin Nutr Met Care 7:569-575; 2004 Wernicke encephalopathy after obesity surgery: A systematic review. Singh S et al. Neurology 68:807-811; 2007 Wernicke’s encephalopathy: new clinical settings and recent advances in diagnosis and management. Sechi G et al. Lancet Neurol 6:442-455; 2007 Nutritional Neuropathies. Kumar N. Neurol Clin 25:209-255; 2007 Vitamin and Trace Mineral Levels after Laparoscopic Gastric Bypass. Madan A et al. Obesity Surg 16:603-606; 2006

    19. Questions

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