Bariatric Times

NOV 2017

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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17 Review Bariatric Times • November 2017 t he skin. 1 1 C ryoglobulinemia is also common, and immunoglobulins to Escherichia coli (E coli) and Bacteroides fragilis (B fragilis) have been detected in some p atients. 1 2,13 I nterestingly, BADAS has also been observed in non-bypass surgery patients with chronic bowel inflammation, including inflammatory colitis and diverticulitis, 11 further s upporting this syndrome's mechanistic relationship to bacterial overgrowth. Researchers have also reported the occurance of BADAS in other surgical procedures that create a blind bowel loop, including biliopancreatic diversion, 14 RNYGB, 15 partial gastrectomy with Roux-en-Y jejunostomy, 16 and Billroth II gastrectomy. 17 Thus, SIBO-associated c omplications following JIB are not just a topic of historical interest, but remain clinically relevant to understanding complications of infectious or immune-mediated g astrointestinal diseases and of surgical procedures that create a blind bowel loop. ROUX-EN-Y GASTRIC BYPASS AND SIBO As JIB has been phased out of surgical practice, SIBO-related complications of bariatric surgery have received less clinical attention. Rates of development of post- surgical SIBO have dropped, and symptoms of SIBO resemble those observed following RNYGB and biliopancreatic diversion with duodenal switch procedures themselves, including weight loss, steatorrhea, abdominal discomfort and bloating, vitamin deficiencies (especially A, D, E, K, Fe, and B12), and hypoalbuminemia, 3,18,19 making it difficult to diagnose. SIBO might be suspected in cases where vitamin deficiencies or weight loss seem to be outside the normal range, and other diagnoses are excluded. For example, while thiamine deficiencies are common following bariatric surgeries, two retrospective studies of 80 and 21 patients with obesity who underwent RNYGB reported that the presence of SIBO could explain post-operative thiamine deficiency accompanied by folate excess or unresponsiveness to supplementation, which are unusual. 20 Of the 80 patients in the first study, 39 (49%) had low thiamine levels, and of these, 28 (72%) had elevated serum folate. Meanwhile, high serum folate was more rare in the 41 patients with normal serum thiamine (p<0.01). The authors suggest that the combination of low serum thiamine and high serum folate might indicate SIBO. Indeed, 15 patients with low serum thiamine had positive hydrogen breath tests 30 minutes after an oral dose of glucose. The second study involved 21 patients with thiamine deficiency and e vidence of SIBO by hydrogen breath testing. Oral thiamine supplementation alone failed to correct this deficiency, while oral antibiotics combined with thiamine s upplements led to normal thiamine levels in nine patients. In other cases, SIBO can present with more dramatic symptoms. In a case series of two female patients w ho had undergone RNYGB, elevated respiratory hydrogen tests were observed in conjunction with total body weight loss of 52 percent and 34 percent within 21 and 15 months o f surgery, respectively, and was accompanied by asthenia, alopecia, edema, and hypoalbuminemia (to 24g/L and 34g/L, respectively). 21 Both patients received 30 days of c iprofloxacin and tetracycline antibiotic therapy, which led to resolution of their symptoms. While the retrospective nature of these studies and small sample sizes p reclude drawing strong conclusions about the role of SIBO, clinical awareness of SIBO as a potential cause of persistent vitamin deficiencies and total protein m alnutrition in patients who have undergone bariatric surgery can guide management toward hydrogen breath testing and antibiotic therapy. With proper therapy, symptomatic r elief for these patients and prevention of the development of serious complications such as Wernicke encephalopathy can be achieved. 22,23 B ecause of the rarity of SIBO following RNYGB, optimal treatment is poorly understood. Management strategies include providing nutritional support, addressing the M l i l fi i F i h ld d l AF A FREE UP ST i i FF ee - Thr - Several atta - Multiple configurati om flexible holder options, fr achments available to suit varying needs - ions to hold scopes and lapar e to rigid - arying needs - oscopic instruments - ar

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