Nutrition Support Blog: Micronutrients and Feeding Site
August 8, 2011
It is an interesting phenomenon that classroom lessons, regardless of a teacher’s skill, never seem to leave an impression as indelible as an actual case in practice. I distinctly remember learning about portal hypertension in school, but I don’t believe that I ever really “got it” such that I fully understood the pathophysiology and ramifications until I saw cases of variceal bleeding in the ICU. Likewise, we have all learned about sites of nutrient absorption, but it has taken several sentinel cases to remind us of the need to monitor nutrient status whenever a site for ideal absorption is bypassed.
There have been a number of cases of copper deficiency reported in the literature after gastric bypass.1-4 Unfortunately, many of the cases reported in the literature experienced severe micronutrient deficiencies that did not become detected until significant hematologic or neurologic symptoms developed.
One notable case was a patient with a history of gastric bypass for weight loss that developed a severe rash. A dermatologist quickly identified the classic erythematous patches as consistent with severe zinc deficiency. The lesions were the classic pattern seen in Acrodermatitis enteropathica, an autosomal recessive disorder which affects the absorption of zinc. However, a rash in adults with zinc deficiency is uncommon because it generally only occurs in the setting of severe deficiency, and Acrodermatitis enteropathica is generally identified and treated in childhood. The patient was ultimately found to have severe deficiencies of zinc and copper due to the combination of gastric bypass, poor intake, and poor compliance with vitamin/mineral supplements.
The number of case reports in this population highlights the need for a more organized approach for monitoring these patients when we know that we are bypassing the optimal sites for the absorption of several important trace elements. Now that we have become sensitized to the micronutrient deficiencies associated with gastric bypass, we have begun to monitor these patients, and have identified a variety of deficiencies including zinc, copper, iron, selenium and several B-vitamin deficiencies.
If you are interested in more information relating to gastric bypass check out our Webinar schedule available at www.GInutrition.virginia.edu (click on Nutrition Support Webinars). Kelly O’Donnell, MS, RD, CNSD will be discussing vitamin and mineral issues in gastric bypass in November.
1) Choi EH, Strum W. Hypocupremia-related myeloneuropathy following gastrojejunal bypass surgery. Ann Nutr Metab. 2010;57(3-4):190-2.
2) Pineles SL, Wilson CA, Balcer LJ, et al. Combined optic neuropathy and myelopathy secondary to copper deficiency. Surv Ophthalmol. 2010;55(4):386-92.
3) Rojas P, Carrasco F, Codoceo J, et al. Trace element status and inflammation parameters after 6 months of Roux-en-Y gastric bypass. Obes Surg. 2011;21(5):561-8.
4) O'Donnell KB, Simmons M. Early-onset copper deficiency following Roux-en-Y gastric bypass. Nutr Clin Pract. 2011;26(1):66-9.
“Self-confidence serves as a virtue when we are able to step back and re-examine our assumptions; when our sense of mission is tempered by a realistic acceptance of our limited vision; and when we acknowledge that, often as not, high-minded intentions and efforts can and do produce collateral damage.” -unknown