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Secondary Kwashiorkor: A Rare Complication of Gastric Bypass Surgery

2014; Elsevier BV; Volume: 128; Issue: 5 Linguagem: Inglês

10.1016/j.amjmed.2014.12.002

1555-7162

Jeffrey H. William, Elliot B. Tapper, Eric U. Yee, Simon C. Robson,

Diet and metabolism studies

Bariatric surgery often improves health outcomes for morbidly obese patients and is increasing in popularity. Although functional malabsorption is less common with modern surgical techniques, the procedure can still contribute to acquired food intolerance and maladaptive eating behaviors that can precipitate or worsen preexisting nutritional deficiencies. When severe, this can lead to protein-energy malnutrition, or kwashiorkor. Although more common in resource-poor countries, it is also an underrecognized form of malnutrition in hospitalized patients in Western countries for whom it is often secondary to nondietary causes, including malabsorption, chronic alcoholism, kidney disease, severe burns, and bariatric surgery.1McLaren D.S. Skin in protein energy malnutrition.Arch Dermatol. 1987; 123: 1674-1676aCrossref PubMed Scopus (32) Google Scholar We describe a 42-year-old woman after Roux-en-Y gastric bypass surgery with secondary kwashiorkor, characterized by edema, dermatoses, exocrine pancreatic insufficiency, and hepatosteatosis (Figure 1A).Case ReportA 42-year-old woman with a history of a Roux-en-Y gastric bypass surgery in 2001 was transferred to Beth Israel Deaconess Medical Center with cachexia and anasarca. Her postoperative course had been marked by early satiety and poor nutritional intake over the next 10 years. Months before admission, she developed malodorous stools along with an enlarging abdomen, followed by anasarca with weeping blisters and erythema. Physical examination showed temporal wasting, scleral icterus, angular cheilitis, and thinning and depigmented hair. The skin over her body was free of spider angiomata and palmar erythema, but her fingertips were peeling with a purple discoloration. The abdomen was distended with shifting dullness, but without caput medusae. Laboratory studies were as shown in Figure 1B. Endoscopy revealed duodenal villous blunting. Percutaneous liver biopsy demonstrated severe hepatosteatosis and inflammation without Mallory hyaline inclusions, consistent with nonalcoholic steatohepatitis given her lack of alcohol intake and strong collateral history.DiscussionSecondary kwashiorkor after bariatric surgery may be an underrecognized cause of malnutrition, which can develop after self-prescribed modifications in diet to achieve greater weight loss by substituting whole foods and protein with carbohydrate-rich, high-calorie alternatives. Kwashiorkor has numerous entities demonstrated by our patient, including (1) hepatosteatosis secondary to decreased hepatic synthesis of plasma beta-lipoproteins and intestinal epithelial-barrier dysfunction leading to hepatic necroinflammation2Trehan I. Goldbach H.S. LaGrone L.N. et al.Antibiotics as part of the management of severe acute malnutrition.N Engl J Med. 2013; 368: 425-435Crossref PubMed Scopus (220) Google Scholar; (2) exocrine pancreatic insufficiency due to the high rate of protein turnover; (3) edema secondary to ineffective hepatic inactivation of antidiuretic hormone and ferritin release from damaged hepatocytes promoting further increased antidiuretic hormone secretion and hyperaldosteronism3Srikantia S.G. Gopalan C. Role of ferritin in nutritional edema.J Appl Physiol. 1959; 14: 829-833PubMed Google Scholar; and (4) dermatoses, represented by changes in hair characteristics (depigmented and brittle) along with a multitude of skin findings from an array of combinations of vitamin and micronutrient deficiencies.4Mann D. Presotto C. Queen S.M. Oliveira E.F. Gripp A.C. Cutaneous manifestations of kwashiorkor: a case report of an adult man after abdominal surgery.An Bras Dermatol. 2011; 86: 1174-1177Crossref PubMed Scopus (5) Google ScholarConclusionsOur patient presented with numerous findings consistent with iatrogenic secondary kwashiorkor, attributable to malabsorption from Roux-en-Y gastric bypass surgery and maladaptive eating behaviors. Longitudinal, multidisciplinary care involving surgeons, internists, and dietitians can provide a supportive environment for those at risk for nutritional complications and maladaptive eating behaviors after bariatric surgery. Bariatric surgery often improves health outcomes for morbidly obese patients and is increasing in popularity. Although functional malabsorption is less common with modern surgical techniques, the procedure can still contribute to acquired food intolerance and maladaptive eating behaviors that can precipitate or worsen preexisting nutritional deficiencies. When severe, this can lead to protein-energy malnutrition, or kwashiorkor. Although more common in resource-poor countries, it is also an underrecognized form of malnutrition in hospitalized patients in Western countries for whom it is often secondary to nondietary causes, including malabsorption, chronic alcoholism, kidney disease, severe burns, and bariatric surgery.1McLaren D.S. Skin in protein energy malnutrition.Arch Dermatol. 1987; 123: 1674-1676aCrossref PubMed Scopus (32) Google Scholar We describe a 42-year-old woman after Roux-en-Y gastric bypass surgery with secondary kwashiorkor, characterized by edema, dermatoses, exocrine pancreatic insufficiency, and hepatosteatosis (Figure 1A). Case ReportA 42-year-old woman with a history of a Roux-en-Y gastric bypass surgery in 2001 was transferred to Beth Israel Deaconess Medical Center with cachexia and anasarca. Her postoperative course had been marked by early satiety and poor nutritional intake over the next 10 years. Months before admission, she developed malodorous stools along with an enlarging abdomen, followed by anasarca with weeping blisters and erythema. Physical examination showed temporal wasting, scleral icterus, angular cheilitis, and thinning and depigmented hair. The skin over her body was free of spider angiomata and palmar erythema, but her fingertips were peeling with a purple discoloration. The abdomen was distended with shifting dullness, but without caput medusae. Laboratory studies were as shown in Figure 1B. Endoscopy revealed duodenal villous blunting. Percutaneous liver biopsy demonstrated severe hepatosteatosis and inflammation without Mallory hyaline inclusions, consistent with nonalcoholic steatohepatitis given her lack of alcohol intake and strong collateral history. A 42-year-old woman with a history of a Roux-en-Y gastric bypass surgery in 2001 was transferred to Beth Israel Deaconess Medical Center with cachexia and anasarca. Her postoperative course had been marked by early satiety and poor nutritional intake over the next 10 years. Months before admission, she developed malodorous stools along with an enlarging abdomen, followed by anasarca with weeping blisters and erythema. Physical examination showed temporal wasting, scleral icterus, angular cheilitis, and thinning and depigmented hair. The skin over her body was free of spider angiomata and palmar erythema, but her fingertips were peeling with a purple discoloration. The abdomen was distended with shifting dullness, but without caput medusae. Laboratory studies were as shown in Figure 1B. Endoscopy revealed duodenal villous blunting. Percutaneous liver biopsy demonstrated severe hepatosteatosis and inflammation without Mallory hyaline inclusions, consistent with nonalcoholic steatohepatitis given her lack of alcohol intake and strong collateral history. DiscussionSecondary kwashiorkor after bariatric surgery may be an underrecognized cause of malnutrition, which can develop after self-prescribed modifications in diet to achieve greater weight loss by substituting whole foods and protein with carbohydrate-rich, high-calorie alternatives. Kwashiorkor has numerous entities demonstrated by our patient, including (1) hepatosteatosis secondary to decreased hepatic synthesis of plasma beta-lipoproteins and intestinal epithelial-barrier dysfunction leading to hepatic necroinflammation2Trehan I. Goldbach H.S. LaGrone L.N. et al.Antibiotics as part of the management of severe acute malnutrition.N Engl J Med. 2013; 368: 425-435Crossref PubMed Scopus (220) Google Scholar; (2) exocrine pancreatic insufficiency due to the high rate of protein turnover; (3) edema secondary to ineffective hepatic inactivation of antidiuretic hormone and ferritin release from damaged hepatocytes promoting further increased antidiuretic hormone secretion and hyperaldosteronism3Srikantia S.G. Gopalan C. Role of ferritin in nutritional edema.J Appl Physiol. 1959; 14: 829-833PubMed Google Scholar; and (4) dermatoses, represented by changes in hair characteristics (depigmented and brittle) along with a multitude of skin findings from an array of combinations of vitamin and micronutrient deficiencies.4Mann D. Presotto C. Queen S.M. Oliveira E.F. Gripp A.C. Cutaneous manifestations of kwashiorkor: a case report of an adult man after abdominal surgery.An Bras Dermatol. 2011; 86: 1174-1177Crossref PubMed Scopus (5) Google Scholar Secondary kwashiorkor after bariatric surgery may be an underrecognized cause of malnutrition, which can develop after self-prescribed modifications in diet to achieve greater weight loss by substituting whole foods and protein with carbohydrate-rich, high-calorie alternatives. Kwashiorkor has numerous entities demonstrated by our patient, including (1) hepatosteatosis secondary to decreased hepatic synthesis of plasma beta-lipoproteins and intestinal epithelial-barrier dysfunction leading to hepatic necroinflammation2Trehan I. Goldbach H.S. LaGrone L.N. et al.Antibiotics as part of the management of severe acute malnutrition.N Engl J Med. 2013; 368: 425-435Crossref PubMed Scopus (220) Google Scholar; (2) exocrine pancreatic insufficiency due to the high rate of protein turnover; (3) edema secondary to ineffective hepatic inactivation of antidiuretic hormone and ferritin release from damaged hepatocytes promoting further increased antidiuretic hormone secretion and hyperaldosteronism3Srikantia S.G. Gopalan C. Role of ferritin in nutritional edema.J Appl Physiol. 1959; 14: 829-833PubMed Google Scholar; and (4) dermatoses, represented by changes in hair characteristics (depigmented and brittle) along with a multitude of skin findings from an array of combinations of vitamin and micronutrient deficiencies.4Mann D. Presotto C. Queen S.M. Oliveira E.F. Gripp A.C. Cutaneous manifestations of kwashiorkor: a case report of an adult man after abdominal surgery.An Bras Dermatol. 2011; 86: 1174-1177Crossref PubMed Scopus (5) Google Scholar ConclusionsOur patient presented with numerous findings consistent with iatrogenic secondary kwashiorkor, attributable to malabsorption from Roux-en-Y gastric bypass surgery and maladaptive eating behaviors. Longitudinal, multidisciplinary care involving surgeons, internists, and dietitians can provide a supportive environment for those at risk for nutritional complications and maladaptive eating behaviors after bariatric surgery. Our patient presented with numerous findings consistent with iatrogenic secondary kwashiorkor, attributable to malabsorption from Roux-en-Y gastric bypass surgery and maladaptive eating behaviors. Longitudinal, multidisciplinary care involving surgeons, internists, and dietitians can provide a supportive environment for those at risk for nutritional complications and maladaptive eating behaviors after bariatric surgery.