Nutritional Deficiencies After Bariatric Surgery

March 4, 2016

It is clear that the obesity epidemic in the United States has to lead to an urgent need for treatment.  It is also clear that bariatric surgery has answered that call and is helping to stem the tide for those patients who have tried non-surgical weight loss methods only to fail time and time again.  While the disease of obesity is successfully addressed through surgical intervention, it is evident that certain bariatric procedures result in both macro and micro-nutritional deficiencies at different levels.

Monitoring Post Bariatric Nutritional Deficiencies

The malabsorptive effects of certain bariatric procedures result in a myriad of nutritional deficiencies, all which must be monitored in the post-bariatric surgery population.  We have long advocated for a close relationship with our metabolic specialist physicians in order to ensure that these deficiencies are detected and treated rapidly.  Failure to detect deficiencies can result in many serious metabolic derangements.

Laboratory analysis of these patients can be quite extensive and should include:

• Complete Blood Count (CBC)
• Complete metabolic profile (CMP)
• Serum phosphate
• Serum magnesium
• International normalized ratio (INR)
• Thyroid stimulating hormone level (TSH)
• Full lipid profile
• Parathyroid hormone levels (PTH)
• Urinalysis (UA)
• Full vitamin panel.  This panel should include: Vitamin A, D, K, E, B1, B6, B9 (folate), B12 and vitamin C.  In addition, Iron studies, as well as zinc and copper levels, should be obtained.

Micronutrient-Deficient Encephalopathy

The most serious and puzzling of these nutritional deficiencies is, without question, micronutrient-deficient encephalopathy (MDE).  Thiamine deficiency is the most common etiology of MDE although there are other deficiencies which can also result in cerebral dysfunction and must not be ignored.  The clinical manifestations are varied.  Nystagmus is not uniformly identified in this MDE population, while blurred vision, memory loss, speech difficulties, speech arrests, and paraphasias were common findings.  The problem with MDE patients is that their deficiencies are not always identified and testing typically fails to find the underlying cause.  The only purely successful treatment for MDE patients, who did not respond to thiamine, was the reversal of the malabsorptive procedure.

There are, of course, many common deficiencies that are easily treated if appropriate post-operative monitoring is employed.

Deficiency	Symptoms
Vitamin A	Initially presents with complaints of difficulty seeing at night or an avoidance of driving at night. More severe cases can present with night blindness.
Vitamin B1, B6 or B12	Can present with neuropathies. These include numbness and tingling of the feet, which are typically written off as symptoms of diabetes rather than an underlying vitamin deficiency.
Biotin	Symptoms include hair loss with easily pluckable or sparse hair.
Essential Fatty Acid	Symptoms include Xerosis.
Vitamin C	Symptoms include Petechiae of the skin.
Vitamin K	Symptoms include Ecchymoses of the skin.
Niacin	Can result in Hyperkeratosis, especially in sun exposed areas.
Thiamine	Symptoms begin with peripheral neuropathy and progress proximally to the calves and knees. This progression can be rapid and have been known to do so in just an hour. The resulting Wernicke’s encephalopathy is most commonly seen with post operative vomiting but can also occur long term with poor preoperative nutrition being exacerbated by poor postoperative nutrition.
Iron	Can present in a myriad of ways. Patients can complain of anything from malaise to pica- typically with ice chips.

These are but a handful of the most common examples of deficiencies seen after bariatric malabsorptive procedures, and there are many more.  The underlying key to preventing these deficiencies is careful follow-up and comprehensive monitoring.  There is no question that an internal medicine physician specializing in metabolic medicine is essential to any successful state of the art bariatric surgery program.  It is only through the tight monitoring of the post-bariatric surgery patient that deficiencies can be identified, addressed and treated in a timely fashion.

ABOUT THE AUTHOR Michael Jay Nusbaum, MD, FACS, FASMBS started the Laparoscopic Bariatric Program at Saint Barnabas Medical Center in 2000. He has performed over 2,000 laparoscopic gastric bypasses and over 1,500 laparoscopic gastric banding procedures. He currently practices at Obesity Treatment Centers of New Jersey. Read more articles by Dr. Michael Jay Nusbaum!

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