Hi all,
My (new) rheumatology doctor wants me to ask those who have had wls (my type specifically, the DS)...

...if anybody has had a case of Rheumatoid Arthritis as a postop, where they didn't have RA as a preop? 

I believe he's looking for an overgrowth of bacteria in the shorter-transit intestine, or looking for another reason for the immune system to attack itself BECAUSE OF this wls. . .

anybody who has thoughts on this...please share...

:-)
anne

I haven't had it, but I've heard of it (or something like it).  There was a DSer who lives/lived here in San Jose, whom I met for lunch when I was pre-op - Melanie? Melinda?  Last name began with a B - she was a member here, I think.  Bah, I can't remember.  She didn't participate for long here.

Anyway, she told me she had had this, not too long after her DS.  Inflammatory arthritis in her joints, and a rash.  She had it for months before her docs thought to treat with massive antibiotics to clean out ALL limbs (hint: Xifaxin won't work for that!), and probiotics to start over - the expensive kind, I think, like VSL3. (http://vsl3.com/), and it cleared up.

Here are a few resources:
http://www.duodenalswitch.com/forum/showthread.php?t=9243

Oh holy crap - I remembered her name, and I figured out how to search her on OH's CRAPPY serach function and I found her profile - and she still has her story posted!
http://www.obesityhelp.com/morbidobesity/members/profile.php ?N=B990597713

Her condition was called Erythema Nodosum.  Here is Margy's discussion:
"This can apparently happen sometimes after bariatric surgery. Bacteria builds up in the intestine and causes the syndrome. The symptoms are weird red swollen masses all over the arms and legs. The worst symptom is that it attacks all of the joints like rhumatoid arthritis and I was left unable to walk or use my arms well. It's very painful and has been quite an ordeal.

My PCP along with my surgeon determined what it was this week and I'm now on antibiotics and steroids. I feel about 1000% better today than I did a few days ago."

It took her a while to recover, but she did!

Here is another diagnosis:
Clin Ter. 2011 May-Jun;162(3):e89-92.

Henoch-Schönlein purpura in a patient with bowel bypass syndrome.

Danese C, Iuorio A, Iuorio R, Lorusso C, Librando A, Colella A, Della Grotta G.

Source

Departments of Internal Medicine and Medical Specialities, "Sapienza" University of Rome, Italy. [email protected]

Abstract

Henoch-Schönlein purpura (HSP) is a common vasculitis being characterized by the classic tetrad of nonthrombocytopenic palpable purpura, arthritis or arthralgias, gastrointestinal and renal involvement. Antigen-antibody (IgA) complexes activate the alternative complement pathway, resulting in inflammation and small vessels vasculitis. We present the case of a 53 years old Italian woman with HSP who was previously hospitalized for purpura skin lesions of the lower legs and diarrhea; a skin biopsy showed a leukocytoclastic vasculitis with perivascular accumulation of neutrophils and mononuclear cells. She was treated with immunosuppressive therapy. After 8 months she was hospitalized again for a recurrent episode of purpura skin lesions of the lower legs. At age 49 she was affected by obesity (BMI = 41.6 Kg/m2), treated via a bilio-pancreatic diversion that led, within a year, to a BMI reduction (25 Kg/m2). We suppose that bariatric surgery played a role on the development of autoimmune phenomena and that the formation of immunecomplexes is secondary to the excess of intestinal bacterial antigens. A cyclic therapy with Paromomicine 500 mg twice daily and Metronidazole 250 mg twice daily was performed with a clear up of the clinical picture. In medical literature are described numerous complications whi*****lude arthritis, erythema nodosum-like lesions, eruptions and other skin manifestations in patients who have undergone jejunocolic bypass. This case report describes for the first time the presence of HSP in a patient with bowel bypass syndrome and it is also able to demonstrate the relationship between the intestinal bacterial overgrowth and the systemic autoimmune system.


I hope your rheumy can flush you out and get you fixed up.

Leaky gut - have him look into that as well (although that name isn't given much credence), as well as SBBOS or SIBO.

In any case, antibiotics (as well as steroids until the inflammation goes down?), probiotics, gluten-free to prevent irritation to an already damaged gut, etc.  But this is NOT unknown, and yes, probably related to your DS.

Standing here beside of myself in awe.......
(and -- bookmarking)

 Wow Diane, what an incredible resource you are. I can only imagine how much pain she would have suffered while her docs figured this out. You truly are a life saver!

Erythema nodosum isn't the same as RA (though I get why you posted about it) and has many potential causes, one of which could be any type of surgery, not just bariatric surgery. There is a laundry list of potential causes. My point being that I wouldn't blame the DS specifically even though that's the type of surgery she had, but rather the stress of major surgery, possibly the antibiotics she was given for the surgery, etc etc.
     I do believe that the gut is involved in the immune system, probably in ways we don't fully understand, and that messing with the gut can mess with your immune system. But I've never heard of the DS causing RA or any other specific autoimmune disease. Not saying it's impossible, just that I've never heard of it as a specific cause, that people can develop RA at any point in life and we don't know why, and that I wouldn't be too quick to blame the surgery for something that could have happened with or without surgery. After all, the overwhelming majority of people with RA and other autoimmune diseases have NOT had any form of wls before their illnesses developed.

Larra

You're right of course - but rheumatoid and reactive arthritis may both have origins in an autoimmune response to antigens getting into the bloodstream.  In this case, it may be that the antigens are coming from the gut, where bacterial overgrowth and toxins or other byproducts from the bacteria are causing the gut to become too permeable.  I think the common factor is autoimmunity - but the nomenclature matters, e.g., with respect to the diagnostic codes and specific treatments.

In any case, her rheumy should be able to figure this out from the literature, from blood tests to see what antibodies are present, and other doctor-y things.  One of the syndromes I mentioned above resulted from inflammation of the subcutaneous fat; I'm sure in some case, it might be a different organ or cell type that is targeted by the autoantibodies.  Or it could be a more generalized inflammatory process, which would require a different treatment.

In any case, blasting with antibiotics seems to be at least a reasonable first step, right?  After he figures out whether and if so which bugs are the predominant species that have overgrown.

I used to only look this way at Kirmy, but Diana I am so impressed right now.  Thank GOD for you on this board.  

Bookmarked!

 This is why I think Diana Cox is so very, very awesome!

I am saving this for sure! Awesome info Diana!