ESPEN Congress Geneva 2014 The undesirable weight loss: malnutrition in bariatric patients. A case presentation F. Pralong (CH)

Transcription

1 ESPEN Congress Geneva 2014 The undesirable weight loss: malnutrition in bariatric patients A case presentation F. Pralong (CH)

2 The undesirable weight loss: malnutrition in bariatric patients A case presentation ESPEN 2014 François Pralong Service of Endocrinology, Diabetology and Metabolism Lausanne, Switzerland

3 First visit: march 1999 Mrs C.C-M 24 yo female patient in good general health, referred by GP for a bariatric procedure kg for cm (BMI=41.3 kg/m 2 ) Weight history overweight since infancy age 15 yo: 75 kgs yoyos (+/- 15 to 20 kg), with many different restrictive diets (WW ) Max weight: kg. Min weight: 80 kg intermittent use of fluoxetine and amphetamines since age 18

4 Questions Is there an indication for bariatric surgery? Do you need more information?

5 Mrs C.C-M Pre-operative w/u sleep apnea syndrome : CPAP biology: Ca, PTH, VitD, Vit B12, folate, ferritin all within normal limits Glucose, HbA1C, lipid profile all within normal limits byte score: 4/0 Sept 1999: Gastric banding

6 Questions Why banding? Which follow up?

7 Mrs C.C-M : Clinical evolution after gastric banding May 2000 loss of >30 kg major improvement of sleep apnea syndrome : stop CPAP June 2001 mammary reduction abdominoplasty lipoaspiration of the thighs Sept 2001 (2 yrs after GB) 64.4 kg (loss of 53.6 kg, BMI= 23.8 kg/m2) at surgery: excess weight = 44.1 kg

8 Mrs C.C-M : Evolution of biological w/u after gastric banding Norms/Units Pre-op M6 M12 M24 Dates Hb g/l Calcium 2,10 2, (corrected) mmol/l Tot g/l proteins Ferritin μg/l Folic acid > 5,3 nmol/l Vitamin B12 pmol/l Phosphate mmol/l PTH ng/l OH vit. 8,4 52,3 μg/l D3

9 Comments?

10 Mrs C.C-M : Clinical evolution after gastric banding May 2000 loss of >30 kg major improvement of sleep apnea syndrome : stop CPAP June 2001 mammary reduction abdominoplasty lipoaspiration of the thighs Sept 2001 (2 yrs after GB) 64.4 kg (loss of 53.6 kg, BMI= 23.8 kg/m2) January 2002 lost to F/u (married, moved to USA)

11 Mrs C.C-M : Clinical evolution after gastric banding April kg (sept 2001: 64.4 kg) Recurring unspecified feeding disorder intervention by dietician over several months April 2007 (unknown to us) Conversion of banding into gastro-jejunal bypass for recurring morbid obesity, with short common loop of 150 cm (another hospital)

12 Question What are the indications for reoperation?

13 Flashback : Clinical evolution after bypass Dec 2008 (18 months after jejunal bypass) 61 kg (BMI=22.7 kg/m2) Diarrhea Vomiting (morning) Weakness of legs, edemas (legs, hands, face) Secondary amenorrhea Episodes of dizziness after CH-rich meals

14 Comments?

15 Flashback : Clinical evolution after bypass October 2009 : outpatient gastro-enterologist visit Main complaints: asthenia, diarrheas (3-10/d), vomiting, massive loss of hair PE: 54 kg (-7, BMI=20.1 kg/m2); 104/76 mmhg; lower limb edemas up to the knees

16 Flashback : Clinical evolution after bypass October 2009 : outpatient gastro-enterologist visit Biological w/u: Albumin : 24 g/l Zn : 7μmol/L ( ) Ferritin, vit A, B1, B2, B6, B12, folic ac, vit D3 all within normal limits Coloscopy (and biopsies): within normal limits Conclusions: hypoalbuminuria of unclear origin, in context of gastro-jejunal bypass steatorrhea

17 Flashback : Clinical evolution after bypass Hospitalization for w/u of malnutrition and malabsorption We are called at ward Overall conclusions: Hypoalbuminemia secondary to low protein intake Irregular food intake with consequent tendency to hypoglycemias All due to lack of information on nutritional adaptations after malabsorptive surgery

18 Comment Recommendations for nutritional adaptations after surgery Recommendations for micronutriments substitution

19 Mrs C.C-M : treatment f/u after hospitalization Nutritional supplementations : Dates Folic acid 5 mg/d 5 mg 5/7d Hydroxycobalamin Depot mg 1 amp/2 weeks 1 amp/mo Mg mg 2 pills/d 2 pills/d Pil-Food* 3 pills/d stop * Pil-Food DL-méthionine 200 mg, cystine 105 mg, lactalbumin 25 mg, millet 20 mg, DL-αtocophérol acétate 3 mg, riboflavine 1 mg, pyridoxine 12,15 mg, calcium pantothenate 25 mg, biotin 0,2 mg, excipients. Dietary recommendations: Increase protein intake Increase fluid intake

20 Mrs C.C-M : clinical f/u after hospitalization October 2009: f/u outpatient visit 2 weeks after discharge : PE:56 kg (+2, BMI= 20.8 kg/m2); BP: 102/63 mm Hg; HR 97/min; presence of ankle edemas January 2010 PE: 58.7 kg (+2.7 kg) Intermediate history: Decrease of edemas Decrease of losing hair Decrease of diarrheas Increase in energy levels, increase in strength Menstruations on

21 Mrs C.C-M : biological f/u after hospitalization Norms/Units M30 M33 Dates Hb g/l ,10 2,50 mmol/l Calcium ,10 (corrected) Proteins tot g/l Albumin g/l Iron 10,7-21,4 μmol/l 18 16,7 Ferritin μg/l Vitamin B1 > 115 nmol/l 254,1 211,4 Vitamin B nmol/l 335,7 402,3 Vitamin B nmol/l 107,5 136,2 Folic acid > 5,3 nmol/l 24,5 32,4 Vitamin B pmol/l Zinc 10,7-17,5 μmol/l 11,3 10,6 Mg érythrocyt. 1,96 2,40 mmol/l 1,94 2,32 PTH ng/l OH vit. D3 8,4 52,3 μg/l 22,7 25,2 Vitamin A 1,05-2,0 9µmol/l 0,9 0,9 Vitamin E 11,6-41,8 µmol/l 15,6 18

22 Mrs C.C-M : treatment f/u after hospitalization Dates Janvier 2011 Folic acid 5 mg/d 5 mg 5/7d 5 mg 5/7d Hydroxycobalamin Depot mg 1 amp/mo 1 amp/mo 1 amp/2 mo Mg mg 2 pills/d 2 pills/d 3 pills/d Magnesium hydrochloride 10 mmol Pil-Food* 3 pills/d stop - Iron (III) hydroxydepolymaltose mg/d Stop (intolerance) Ca carbonate 2500 mg/ Cholecalciferol 800 IU - 1 daily 1 daily * Pil-Food DL-méthionine 200 mg, cystine 105 mg, lactalbumin 25 mg, millet 20 mg, DL-αtocophérol acétate 3 mg, riboflavine 1 mg, pyridoxine 12,15 mg, calcium pantothenate 25 mg, biotin 0,2 mg, excipients.

23 Mrs C.C-M : clinical f/u after hospitalization September 2010 PE: 67.6 kg (+9 kg), stable last 4 months; BMI= 25.1 kg/m2 Intermediate history: Feels a lot better No losing hair, no diarrheas, no vomiting Disappearance of ankle edemas February 2011 PE: 67.7 kg, stable since last visit; BMI= 25.1 kg/m2 Intermediate history: No specific complaint Desire of fertility

24 Mrs C.C-M : surprise June 2011 PE: 75.8 kg (+7.1) Pregnant (twin pregnancy), 18 weeks

25 Mrs C.C-M : biological f/u after pregnancy Norms/Units M49 5 yrs 6 yrs Dates Hb g/l Calcium (corrected) 2,10 2,50 mmol/l Albumin g/l Ferritin μg/l Vitamin B1 > 115 nmol/l Vitamin B nmol/l Vitamin B nmol/l Folic acid > 5,3 nmol/l Vitamin B pmol/l Pre-albumin 0,2-0,4 g/l Zinc 10,7-17,5 μmol/l Mg (erythrocyt) 1,96 2,40 mmol/l PTH ng/l OH vit. D3 8,4 52,3 μg/l Uneventful delivery : sept 2011

26 Mrs C.C-M : Treatment f/u during pregnancy Dates June 2011 August 2012 Folic acid 5 mg 5/7d 5 mg 3/7d Hydroxycobalamin Depot mg 1 amp/2 mo 1 amp/mo Mg mg 2 pills/d 2 pills/d Magnesium hydrochloride 10 mmol 1 daily stop Pil-Food - - Iron (III) hydroxydepolymaltose Ca carbonate 2500 mg/ Cholecalciferol 800 IU Iron (saccharate) 100 mg Cholecalciferol 300'000 UI pill/d 2 pills/d 1 amp/2 mo Single inj Uneventful delivery : sept 2011

27 A happy end : Christmas 2013