Gastric Bypass: Copper Deficiency Anemia

Abstract

Introduction: This case is regarding anemia secondary to copper deficiency. Copper deficiency may present in different ways, but is usually microcytic and hypochromic. It may cause pancytopenia and myeloneuropathy. Copper is mostly absorbed in the stomach and duodenum. It's essential for the absorption and utilization of iron. Most often copper deficiency is noted after a gastric bypass, gastrectomy, or small bowel resection. Another well known cause is chronic zinc supplementation. Copper supplement recommendations are approximately 900 ug per day for males and non-pregnant females older than 19 years. Case Report: 40-year-old female presents with weakness, and edema. She has had recent hospitalizations with similar symptoms and a history of multiple blood transfusions. On admission hemoglobin level was 7.1 g/dL. No signs of GI bleeding. Has a significant past medical history of hemolytic anemia and aplastic anemia with a past surgical history of a gastric bypass. Medications: furosemide, ferrous sulfate, potassium, prednisone and tramadol. Physical exam: pallor and anasarca. Labs: hemoglobin 7.1 g/dL, hematocrit 27.1%, MCV 101.5 fl, WBC 2.9 g/L, platelets 87 g/L, ferritin 106 ng/mL, iron 65 ug/dL, TIBC 130 ug/dL, % saturation 50%, serum copper level 53 ug/dL (normal 80-155 ug/dL). CT abdomen with IV contrast: hepatic steatosis, normal liver and spleen size, post surgical changes of the gastric body. Hematology was consulted and recommended bone marrow biopsy: 40-45% cellular marrow, slightly hypocellular for age, mild erythoid and megakaryocyte dyspoiesis, no immunophenotypic abnormality, and decreased stainable iron. Intravenous elemental supplementation and high dose IV iron was started. Within 2 days, WBC 5.8 g/L, Hemoglobin 9.7 g/dL, Platelets 109 g/L. Discussion: Approximately 237,000 emergency room visits per year for anemia as the primary diagnosis. This case demonstrates the importance of knowing the past surgical history. Knowing that copper is absorbed mainly in the gastric body and duodenum allows for ordering appropriate tests where malabsorption is a concern. Some suggest that patients who have undergone gastric bypass surgery have copper levels monitored yearly to prevent neurologic conditions because approximately 10-15% is deficient in copper. With obesity more prevalent bariatric surgery is more common. These patients may develop anemia and copper deficiency should be considered in the differential.