In a Case Report published in this week’s edition of The Lancet, researchers study a woman who failed to take multivitamins after weight-loss surgery and subsequently developed a vitamin deficiency.
Dr Rachel Batterham and Dr Alberic Fiennes (Department of Medicine, University College London, UK) and colleagues report on a 27-year-old woman who, 2 months after uncomplicated gastric bypass surgery at University College Hospital (London, UK) suffered from 3 weeks of dizziness, low-appetite, and vomiting. The woman was prescribed standard treatments of multivitamins and lansoprazole after being discharged from weight-loss surgery. Lansoprazole is a drug that prevents the stomach from producing acid.
The woman was examined and diagnosed with gastric outflow obstruction, partially due to her rapid heartbeat and dehydration. However, a camera passed through the digestive system into the stomach (an endoscopy) did not show anything of significance. She lost about 20 kg (44 lbs.) since surgery, and blood tests suggested that she was dehydrated. Physicians gave her intravenous fluids, including glucose, and they told her to drink high-sugar energy drinks. These did not work, however, as she felt light headed, fell down in the shower, and had very low blood pressure the next day. Additional tests found abnormal eye movements, hyper-reflexia in arms (overactive or overresponsive reflexes), weakness of the thighs, and reduced touch sensation. These all pointed towards a deficiency of thiamine, also know as vitamin B1. After doctors administered thiamine intravenously, the patient made a full recovery. She also admitted that she had not been taking her multivitamins.
Vitamin supplements are critical after gastric bypass surgery in order for the body to receive vitamins that are no longer entering the body through food intake. The body stores thiamine for 18 to 60 days, and deficiency can lead to cardiovascular problems or wet beriberi, nervous system problems or dry beriberi, or an acute neurological disorder with eye movement problems called Wernicke’s encephalopathy. The particular woman analyzed in this paper suffered from all three conditions. Among persons in high-income countries, alcoholism is the usual condition that is linked to thiamine deficiency. However, thiamine deficiency is also associate with habitually restricted diets, gastrointestinal disorders, cancer, AIDS, severe infection, and kidney disease. Gastric bypass surgery also can be the root of this condition.
“Wernicke’s encephalopathy most commonly occurs 4-12 weeks after such surgery, mainly in people who have lost more than 7 kg per month. Glucose administration can cause thiamine deficiency to manifest acutely, perhaps by using up remaining thiamine stores. If thiamine deficiency is suspected, thiamine should be administered before a patient is given glucose,” conclude the authors in their report.
“Obesity surgery is becoming increasingly common as it is the only effective treatment for morbid obesity and reduces mortality and obesity associated diseases,” add the authors. “Our case highlights the importance of vitamin supplementation and monitoring of thiamine levels in this patient group. In view of the non-specific nature of the initial beriberi presentation, a low-threshold should be adopted for intravenous thiamine administration, especially prior to high-glucose loads, in patients post-obesity surgery. This could indeed be lifesaving.”
Can glucose make you faint?
S Rahman et al.
The Lancet (2008). 372[9646]: p. 1358.
Written by: Peter M Crosta