Poster Presentation ESA-SRB-ANZOS 2025 in conjunction with ENSA

Severe malnutrition following laparoscopic one anastomosis gastric bypass in a publicly funded bariatric program: A case report (128776)

Emma K Hartley 1 , Mina Toumas 1 , Lisa Sengal 1 , Kathy Grudzinskas 1 , Nick Kormas 1 , Milan Piya 1 2
  1. South Western Sydney Metabolic Rehabilitation and Bariatric Program, Campbelltown and Camden Hospitals, NSW, Australia
  2. Western Sydney University, Sydney

Background:

Pancreatic exocrine insufficiency (PEI) and chronic pancreatitis (CP) are known complications following bariatric surgery(1) and contribute further to malnutrition, micronutrient deficiency, and deteriorating bone health.(1,2) The risk is higher in bypass operations over sleeve gastrectomy.(1)

Case report:

We report a case of severe malnutrition and chronic diarrhoea with evidence of PEI in a 48-year-old male with insulin-dependent type 2 diabetes following one anastomotic gastric bypass for management of class III obesity through a public multidisciplinary metabolic program. Baseline weight was 193kg (BMI 56kg/m2) with mixed metabolic and mechanical obesity-related complications. Following 13% (25kg) weight loss pre-op, he lost a further 73kg post-surgery and 98kg overall (43% from surgery, 51% from peak) doing well initially.

Hospital admission with persistent diarrhoea, anasarca, weakness and skin ulceration occurred four years post-surgery. Diarrhoea pre-dated surgery and pre-surgical workup included coeliac testing, stool culture, virology, faecal elastase level, gastroenterology review and colonoscopy but no CT or MR imaging.

Admission bloodshypoalbuminaemia (13g/L), cholestatic liver function derangement, normal amylase/lipase, elevated prothrombin time, thrombocytopenia and fat-soluble vitamin (A, D, K) and trace element (zinc, selenium, ceruloplasmin). Liver screen was normal; elastography negative for fibrosis and abdominal CT and MRI cholangiopancreatogram suggested CP.  He had hypogonadism, hypothyroidism, secondary hyperparathyroidism and new severe osteoporosis.

Bypass reversal was considered during his six-week admission. Fortunately, he responded to conservative management via high protein oral diet with nutritional supplementation drinks, high-dose intravenous multivitamins, vitamin K, trace elements, thiamine and vitamin D. Empiric mealtime Creon resulted in rapid diarrhoea resolution. Subsequent faecal elastase was 4ug/L, in keeping with severe PEI.

Conclusion:

PEI symptoms are difficult to differentiate from the usual sequelae of bariatric surgery. Delay in diagnosis and treatment can lead to delayed responses, irreversible damage and death. There is room for developing a structured guideline directed approach and long-term follow-up is crucial.

  1. 1. Moore HN, Chirco AR, Plescia T, Ahmed S, Jachniewicz B, Rajasekar G, et al. Exocrine pancreatic insufficiency after bariatric surgery: a bariatric surgery center of excellence experience. Surg Endosc. 2023 Feb;37(2):1466-75.
  2. 2. Vujasinovic M, Valente R, Thorell A, Rutkowski W, Haas SL, Arnelo U, Martin L, Löhr J-M. Pancreatic Exocrine Insufficiency after Bariatric Surgery. Nutrients. 2017; 9(11):1241.