P4894 - Iatrogenic Secondary Kwashiorkor Following Roux-en-Y Gastric Bypass Surgery

Michael Gianarakis, MD¹, Omar T. Ahmed, MD¹, Abdullah Memon, MD², Sandra Naffouj, MD², Itishree Trivedi, MD, MS³, Robert E.. Carroll, MD^1
1University of Illinois at Chicago, Chicago, IL; ²University of Illinois College of Medicine, Chicago, IL; ³University of Illinois, Chicago, IL

Introduction: Rates of post-bariatric surgery nutritional complications have decreased, however are still seen secondary to decreased gastric capacity and malabsorption. Severe protein-calorie malnutrition or kwashiorkor following gastric bypass surgery is extremely rare. The disease is characterized by pitting edema, abdominal distension due to ascites, and hepatic steatosis. Herein, we present a case of a 37-year-old male with a history of Roux-en-Y gastric bypass (RYGB) who presented with clinical findings consistent with kwashiorkor.

Case Description/Methods: A 37-year-old male with a history of RYGB in Mexico 16 months prior presented with worsening anasarca, abdominal distension, and dermatoses of the feet. Laboratory studies demonstrated severe micronutrient, protein deficiency and EPI (Table 1). Evaluation for additional causes of protein loss including intestinal and renal losses was negative. Abdominal magnetic resonance imaging showed moderate volume ascites and diffuse infiltrative disease of the liver with iron and fat content. Abdominal paracentesis was performed with 1.7L of high serum-ascites-albumin-gradient fluid removed. Transjugular liver biopsy showed chronic hepatitis, hemosiderosis and mild macrovesicular steatosis without evidence of cirrhosis. The patient underwent a six-week course of 24-hour enteral feeding via nasojejunal tube consisting of medium chain triglycerides (MCTs) and pancreatic enzyme supplementation. Albumin levels improved to 3.4 gm/dL with resolution of anasarca.

Discussion: Iatrogenic secondary kwashiorkor is a rare complication of RYGB that may be underrecognized. We described a case attributable to post-operative malabsorption manifesting as anasarca, abdominal ascites, metabolic-associated hepatosteatosis, EPI, micronutrient deficiency, and dermatosis. Treatment of post-bariatric surgery kwashiorkor with 24-hr feeds consisting of MCTs and pancreatic enzymes was safe and effective, leading to a rapid rise in albumin levels and resolution of symptoms in our patient. It is important to monitor ammonia levels during treatment to assess for non-hepatic hyperammonemia. This case illustrates the importance of lifelong nutritional follow up after bariatric surgery and the risk posed to patients obtaining surgery abroad who may not have access to follow up care. A multidisciplinary care approach including surgery, gastroenterology, internal medicine, and dietetics should be taken to prevent potentially severe complications including liver failure and infection.


Disclosures:


Michael Gianarakis, MD¹, Omar T. Ahmed, MD¹, Abdullah Memon, MD², Sandra Naffouj, MD², Itishree Trivedi, MD, MS³, Robert E.. Carroll, MD¹. P4894 - Iatrogenic Secondary Kwashiorkor Following Roux-en-Y Gastric Bypass Surgery, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.