Vital Signs

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Ann was my long-time patient, whom I saw with severe gastroesophageal reflux disease, also known as GERD. He was overweight and met the medical standards of morbid obesity. Doctors consider a patient to be obese when they weigh at least 100 kilograms of their ideal body weight, and / or when their weight can significantly contribute to life-threatening conditions such as diabetes, high blood pressure, or fatty liver disease. . Ann was 5 feet 4 inches tall and weighed 250 pounds. As a teenager, she was a 130-pound athlete, but gained weight with each pregnancy.

During one of our clinic visits, the topic of her possible surgery to lose weight was raised. I supported Ann visiting a surgeon who specialized in this area. Such procedures, known as bariatric surgeries, have become extremely common among patients due to their high success rates, often dramatic and life-changing outcomes.

There are several bariatric surgeries, but after meeting with our surgeon, Anne decided to undergo a special bariatric procedure known as Roux-en-Y gastric bypass. This special operation usually leads to a more dramatic weight loss for patients. The operation involves creating a small “bag” made from a portion of the stomach. This purse can only hold a small amount of food at a time է it is connected to a part of the small intestine. The rest of the stomach, which is connected to the top of the small intestine, just stays in place.

But the food digested after the procedure no longer flows through these regions of the gastrointestinal tract. This is the “bypass” mentioned in the action name. Swallowed food bypasses the beginning of the small intestine և enters the intestine, where it is digested far below the line և. After this operation, patients lose weight in several ways. One is that surgery limits how much they can eat at a time, as the purse is too small for a normal stomach. Apart from that, most of the small intestines where food is normally absorbed never see food again. As a bonus, Roux-en-Y gastric bypass is also very effective in treating GERD. Ann underwent surgery without complications.

The first year after the operation was a very exciting time for Annie. He lost almost 75 kilograms, his self-esteem rose, he gave himself a completely new wardrobe. Victory was apparently imminent.

Unexpected difficulty

Therefore, I was understandably surprised to see Annie in my clinic just three months after the one-year surgery anniversary. Looking anxious, he told me that he was constantly feeling weak and tired. He noticed a number of new problems, including changes in his vision, light bruises, and even minor bruises that caused ugly red spots on his hands and feet. Most disturbingly, Annie’s weight loss continued beyond what she could have expected after a gastric bypass. Now he has lost more than 100 kilograms, from strong appearance to, frankly, sick. Most patients have a weight loss plateau near the age of one year, but Annie’s weight continued to decline.

Annie was seriously concerned that she had a cancerous tumor that would explain her weight loss, not unfounded fear. But a CT scan of his abdomen and pelvis does not reveal any obvious abnormalities. I did an upper endoscopy, a colonoscopy, on Anne to make sure there was nothing wrong with her stomach bypassing, to make sure she did not have colon cancer. The procedures failed to reveal anything that could explain her weight loss. But the blood tests I did showed that Anne was suffering from severe malnutrition. Also, her light bruise prompted me to check her vitamin levels, as vitamin K deficiency is often linked to bruises. Her vitamin K level was extremely low, as was her vitamin A level.

Now we have the answer for his vision changes, because vitamin A is necessary for healthy eyesight. Both vitamin K and A are so-called “fat-soluble” vitamins, which means that they do not dissolve in water but in fats. Vitamin A և K deficiencies are rare, և Ann was taking a multivitamin that included both. This suggested that Anne was taking vitamins herself, but her body was simply not absorbing the nutrients they contained.

System failure

When I asked Annie if she had diarrhea, she said she had bowel movements up to four times a day. I asked if his chairs looked oily or greasy. His eyes widened, he nodded. “I have not told anyone yet,” he said. The medical term for oily stool is steatorrhea, and the presence of fat in the stool is a concern. The human body absorbs fat from food very efficiently, probably reflecting earlier times when fat was a rare dietary product. Stool fat, however, is a sign that the body is unable to absorb properly absorbed food. Fat-digesting vitamins are passively absorbed by the body along with the absorbed fat, but if you can not absorb the fat, you can not absorb the fat-soluble vitamins, թեր deficiencies occur.

Most people think that their stomachs digest their food, but in reality it is the pancreas that does most of the work. The pancreas produces enzymes that break down carbohydrates, fats, proteins into their basic building blocks, which can then be absorbed by the small intestine. Steatorrhea is more common in patients with chronic pancreatitis. This condition is usually caused by alcohol abuse, genetic factors or other causes. In these patients, the pancreas becomes scarred, atrophic, and otherwise unable to produce or release enough pancreatic enzymes.

The pancreas is usually responsible for digesting food. (Credit: Kellie Jaeger / Discover)

But Ann did not have chronic pancreatitis. His CT scan showed that the pancreas was normal. However, I began to wonder if Anne was suffering from asynchrony. Sometimes asynchrony can develop after complicated bowel reconstruction, including gastric bypass Rouxen-Y. In order for normal digestion to take place, all parts of the intestine must not only work with the right egg, but also at the right time, in the right place, like a good choreographic ballet. Bypassing Annie’s stomach meant that her food passed through one end of the small intestine, but her pancreas secreted digestive enzymes into the other, there was no food in that area at all. As a result, food does not interact with the enzymes needed to break it down. His body just passed undigested food through him.

I gave Annie a prescription for pancreatic enzymes, pills containing digestive enzymes from pigs, believe it or not. When taken with food, these enzymes activate and break down food, as do human pancreatic enzymes. The small intestine can then absorb these small molecules. Within a few days of starting the medication, Annie’s stool returned to normal and her weight loss stopped. A blood test a few weeks later showed that his vitamin levels were rising.

Ann had to take extra enzymes throughout his life so that his body could maintain the desired weight, և food absorption would be normal. He was not happy about the extra pills, but they worked. Gastric bypass gives, շրջ Gastric bypass goes away.


Douglas G. Adler is co-chair of the Denver Center for Advanced Therapeutic Endoscopy. The cases described in the vital signs are real, but the names and some details have changed.