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Figures
- Figure 1
Commonly performed surgical methods for bariatric surgery a) AGB - Adjustable gastric band. A band with an inner inflatable silastic balloon is placed around the proximal stomach just below the gastroesophageal junction. The band is adjusted through a subcutaneous access port by the injection or withdrawal of solution. b) SG - Sleeve gastrectomy. The stomach is transected vertically creating a gastric tube and leaving a pouch of 100 to 200 mL. c) BPD - Biliopancreatic diversion. A 400 mL gastric pouch is formed from the stomach. The small bowel is divided 250 cm proximal to the ileocecal valve and is connected to the gastric pouch to create a Roux-en-Y gastroenterostomy. An anastomosis is performed between the excluded biliopancreatic limb and the alimentary limb 50 cm proximal to the ileocecal valve. d) RYGB - Roux-en-Y gastric bypass. An upper gastric pouch, of 15 to 30 mL in volume, and a lower gastric remnant is formed from the stomach. The jejunum is divided some 30 to 75 cm distal to the ligament of Treitz, and anastomosed to the gastric pouch. The distal jejunum is brought up as a ‘Roux-limb’. The excluded biliary limb, including the gastric remnant, is anastomosed to the bowel some 75 to 150 cm distal to the gastrojejunostomy.78
Tables
Major disorders Recognized complications Encephalopathy Wernicke’s encephalopathy (WE) Encephalopathy associated with D-lactic acidosis • Hyperammonemic encephalopathy Neuropsychiatric disorders • Frank eating disorders • Anorexia nervosa • Bulimia nervosa • Binge eating behavior • Eating avoidance disorder • Suicide Myelopathy • Posterolateral myelopathy • Myeloneuropathy Optic neuropathy • Nutritional optic neuropathy Other possible conditions (need to be verified by further studies) • Stroke and Seizures • CNS demyelination • Spontaneous intracranial hypotension • Cognitive impairment secondary to focal brain atrophy CNS - central nervous system
Conditions Micronutrient involved and likely pathology Wernicke’s encephalopathy Thiamin (Vitamin B1) deficiency Episodic encephalopathy Elevated D-lactate Hyperammonemic encephalopathy (HAE) Elevated serum ammonia and plasma glutamine levels Zinc deficiency Underlying Urea cycle disorder Myelopathy Cobalamin (Vitamin B12) and Copper deficiency Vitamin E, folate and B6 deficiency (less common) Optic Neuropathy Cobalamin (Vitamin B12) deficiency Vitamin A, Copper and zinc deficiency (less common) Spontaneous intracranial hypotension Vitamin A and D deficiency Spontaneous CSF leakage CSF - cerebrospinal fluid
Complications Diagnosis Treatment Wernicke’s encephalopathy Clinical Intravenous thiamine 500 mg 3 times a day for 2-3 days followed by 250 mg daily for 3-5 days.32,36,38 Erythrocyte transketolase activation assay or RBC thiamine diphosphate Oral maintenance dose of 50-100 mg daily for long term Characteristic paraventricular signals on MRI Encephalopathy associated with D-lactic acidosis: Elevated D- lactate levels in serum and urine Correction of metabolic acidosis High an ion gap metabolic acidosis Carbohydrate restriction Antibiotics43 Hyperammonemic encephalopathy (HAE) Measurement of plasma ammonia, zinc, glutamine and serum albumin level along with genetic testing for OTC enzyme deficiency Dietary protein restriction Parenteral glucose and lipid infusion Repletion of zinc, other micronutrients and amino acids. Hemodialysis44 Reversal of surgical procedure49 Myelopathy secondary to vitamin B12 deficiency Serum B12, methylmalonic and plasma homocysteine levels Intramuscular 1000 mic gram daily for 7 days followed by once weekly and then monthly32 Abnormal signals in dorsal column and corticospinal tract on MRI Myelopathy secondary to copper deficiency Serum and urinary copper Parenteral; intravenous 2 mg daily of elemental copper for 5 days Serum ceruloplasmin activity Oral; 8 mg per day of elemental copper for 1st week, 6 mg for 2nd week, 4 mg for 3rd week and 2 mg thereafter32 MRI findings similar to B12 deficiency Myelopathy secondary to folate deficiency RBCs folate Parenteral; 1-5 mg daily32 Oral; 1 mg 3 times a day then maintenance dose of 1 mg per day RBC - red blood cells, MRI - Magnetic resonance imaging, HAE - Hyperammonemic encephalopathy, OTC - Ornithine transcarbamylase
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