Bariatric Pellagra – Not Just Niacin by Carol Wollin
Background: Pellagra, an old world condition manifesting with dermatitis, diarrhea, dementia and possibly death, has surfaced in the US with the advent of bariatric surgical procedures that limit food intake and absorption. Pellagra is most often associated with a deficiency of niacin and not the niacin precursor tryptophan (Trp), an essential amino acid. The body does not have large stores of niacin and is dependent on the diet for an adequate daily intake. Niacin deficiency leading to Pellagra can be from lack of an adequate daily intake of niacin from food or vitamin supplements or secondary to an inadequate intake of Trpor inability to absorb the amino acid effectively. Bariatric procedures promoting malabsorption such as Roux-en-Y (RYGB), biliopancreatic diversion (BPD) or duodenal switch (DS) increase the risk of developing bariatric Pellagra.
Methods: Case Study: A 32 year-old female patient presents in surgery clinic 10 months following a BPD with glossitis causing an inability to intake oral nutrition, peeling and painful skin on the hands, arms and feet, diarrhea, gastrointestinal discomfort and confusion. She had been seen by a gastroenterologist and a dermatologist two months prior to presenting to the bariatric surgery clinic for these same physical complaints. No clear diagnosis was given to the patient regarding her symptoms. The patient had been placed on daily parenteral vitamin infusions per her gastroenterologist for two months prior to presenting to the bariatric clinic.
Results: This patient was admitted to the hospital and total parenteral nutrition (TPN) was initiated.
Outcome: Symptoms resolved within 24 hours of TPN initiation. Oral diet was tolerated and patient had a substantial increase in alertness. Critical Factors: Pellagra developed despite oral and parenteral multivitamin use. Trp labs during active episodes of Pellagra: 5umol/L, 14umol/L and 4umol/L (normal range 40-91 umol/L). Episodes of Trp deficiency occurred when oral Trp supplement use was discontinued.
Conclusion: A diagnosis of Pellagra in Bariatric patients who have undergone procedures limiting the absorption of nutrients is historically associated with a niacin deficiency. However, Pellagra due to a Trp deficiency will not resolve with niacin therapy alone. A misdirected treatment modality for niacin resistant Pellagra in bariatric patients can result in unwanted health consequences. Health care professional should consider Trp assessment and supplement therapy to avert serious health consequences in the bariatric patient population presenting with symptoms of Pellagra.
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