Dermatology From A to Zinc by Carol Wollin
Postoperative bariatric nutritional deficiencies have multifactorial triggers. Roux-en-Y gastric bypass (RYGB), bilopancreatic diversion (BPD) or duodenal switch (DS) increase the risk of nutritional deficits due to both a reduced gastric capacity and a shortened intestinal pathway for nutrient absorption.
A 46 year old female with a history of Roux-en-Y gastric bypass in 2003 and a revision to a BPD in 2010 due to weight regain began experiencing lightheadedness, unsteadiness, sensitivity to light, and perpetual dizziness in June, 2013. Her neurologist performed lab work, showing a Vitamin D level less than 14 ng/dl (normal 30-100 ng/dl), a Vitamin A level was 2 mcg/dl (normal 38-98 mcg/dl), and a Carotene level below reportable range. While she was given a prescription for Vitamin D, the Vitamin A deficiency was left untreated. She subsequently presented to her bariatric surgeon with worsening symptoms in September, 2013. The patient’s face was now covered in a mass of dark follicular horny papules. She still could not tolerate light, had blurry vision and increased pain in her eyes. She was lethargic and complained of muscle weakness. The patient was admitted to the hospital and started on total parenteral nutrition (TPN). Because no IM/IV Vitamin A is available, large doses of oral Vitamin A was initiated.
In this case, while the obesity was adequately treated by surgery, the diagnosis and treatment of her symptoms from severe nutritional deficiency was not applied in a timely manner. Severe Vitamin A deficiency placed the patient at risk of losing her vision permanently, an impaired immune system, and alteration in skin integrity.
A 38 year old female was admitted to hospital from the ED in December 2013 complaining of PO intolerance, nausea, vomiting, and severe abdominal pain. She had had a sleeve gastrectomy (SG) four months earlier, a paraesophageal hernia and gastric volvulus repair the month following that, and then a revision of her SG to a Roux-en-Y gastric bypass the following month. She experienced persistent PO intolerance since primary SG surgery, so a central line was placed for total parenteral nutrition (TPN). The patient presented in the surgery clinic in mid-February with a pruritic bullous pustular rash on her face and sores in her mouth and vaginal area. Additional oral multivitamin supplementation met with limited success due to PO intolerance and poor compliance. Zinc addition to TPN was limited due to a drug shortage. The patient was admitted to the hospital at the end of February due to abdominal pain, nausea and weakness. Dermatology considered a differential diagnosis of impetigo or herpes and began empirical treatment. Lab results confirmed a zinc level of 12 mcg/dl (normal 60-130 mcg/dl). Vitamin A and D were also deficient.
Bullous acrodermatitis enteropathica acquired from zinc deficiency is rarely encountered in routine clinical practice.
These cases demonstrate the need to have bariatric team members trained to identify and treat nutritional deficiencies. A concerted, multidisciplinary effort helps to promote routine preventative assessments and identify any clinical manifestations of deficiencies requiring treatment before any serious adverse outcomes result. Development of a standardized template to monitor with algorithms to treat would promote long term health in postoperative, bariatric surgery patients.
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