Section: Small bowel Curriculum: Curriculum, page 61
Metabolic Complications
- Protein Deficiency
- Hypoalbuminemia in 0.9 – 2.6%
- Deficiency causes
- Oedema
- Alopecia
- Poor wound healing
- Anorexia
- Recommendation: 90-120g /d
- Monitor albumin + prealbumin 3-6 monthly
- If protein deficiency, difficult to catch up
- Patients cannot eat or drink quickly enough in large volumes
- May need temporary TPN
- Revisional surgery or even reversal for extreme or refractory cases
- Lengthening the common channel or side to side BP to Alimentary limb anastomosis
Decompensated Liver Failure
- Incidence in bariatric patients:
- 37% NASH, 1-7% Cirrhosis
- Bariatric surgery can potentially reverse fatty liver change
- Initial rapid weight loss following surgery can cause hepatic decompensation in pts with NASH
- Possible mechanisms:
- Protein malnutrition
- Deficiency of hepatotrophic factors
- Bacterial overgrowth causing excessive endotoxins
- Accumulation of free fatty acids
Vitamin D Deficiency
- Causes osteomalacia
- Aching pain in the lower limbs, hips, pelvis, lower spine and ribs
- May give weakness of limbs with waddling gate
- Calcium:
- Clinical hypocalcaemia is rare
- Secondary hyperparathyroidism increases bone resorption
- Bisphosphonates without correction of low vitamin D and without Calcium supplements may trigger symptomatic hypocalcaemia
- Monitor intact PTH twice a year
Vitamin E Deficiency
- May cause
- Sensory neuropathy
- Spinocerebellar ataxia
- Areflexia
- Skeletal myopathy
- Haemolytic anaemia
- Check plasma alfa-tocopherol
Vitamin K Deficiency
- May cause easy bleeding or bruising
- Vit K dependent factors 2, 7, 9, 10
- Monitor twice yearly PT
- Prevention: 300 mg/day
Vitamin A Deficiency
- Symptoms
- Xerophthalmia
- Pathologic conjunctival dryness
- Nyctalopia
- Night blindness
- Follicular hyperkeratosis
- Monitor twice yearly plasma Retinol
Vitamin C Deficiency
- Early
- Lethargy
- Weakness
- Irritability
- Weight loss
- Vague myalgias and arthralgias
- Late
- Follicular hyperkeratosis
- Coiled hair
- Perifollicular haemorrhages
- Poor wound healing
- May develop femoral neuropathy, leg oedema, and painful joint effusion
- Could measure plasma ascorbic acid levels
- Treatment: Standard multivitamins BID should be enough
Vitamin B2 (Riboflavin) Deficiency
- Causes
- Stomatitis
- Mucous membrane inflammation
- Cheilosis
- Inflammation and cracking of corners of mouth
Vitamin B6 (Pyridoxine) Deficiency
- Causes
- Seborrheic Dermatitis
- Red scaly greasy itchy inflamed skin
- Commonly on scalp, face, chest
Vitamin B1 (Thiamine) Deficiency
- May occur after as little as 2 weeks of persistent vomiting or as a result of bypass of the jejunum
- T ½ 9-18 days
- Causes:
- Peripheral neuropathy, fatigue, irritability,
- Wernicke Encephalopathy
- Ophthalmoplegia
- Nystagmus
- Ataxia
- Apathy
- Coma
- Korsakoff psychosis
- Confusion
- Dysphonia
- Confabulation
- Dry Beriberi (Peripheral nervous system)
- Bilateral symmetric, stocking-glove distribution paraesthesias/dysesthesias
- Muscular cramps and muscular wasting
- Wet Beriberi (Cardiovascular)
- Vasodilation, tachycardia, wide pulse, warm skin, lactic acidosis, CHF and shock
- Anaemia
- Give IV multi-vits, if in doubt give thiamine 100mg IV
- NB: Test takes 1 week so treat empirically
Selenium Deficiency
- Deficiency may cause
- Selenium-deficient Dilated Cardiomyopathy
- Acute severe heart failure
- Muscular weakness and muscular cramps
- Selenium-deficient Dilated Cardiomyopathy
- Measure
- RBC Glutathione Peroxidase activity
- RBC Selenium
Copper Deficiency
- Deficiency may cause
- Anaemia
- Leukopenia
- Ageusia (loss of taste)
- Ataxia
- Myelopathy
- Peripheral neuropathy
- Paraesthesias in feet +/-hands
- Measure serum copper levels
- NB: Zinc and Iron supplementation may aggravate Copper deficiency
Zinc Deficiency
- Causes:
- Acrodermatitis enteropathica rash
- Abnormal smell and taste
- Hair loss
- Diarrhoea
- Night blindness
- Altered memory
- Diagnosis: Serum Zinc levels