Severe Nutritional Myelopathy After Roux-En-Y Gastric Bypass: A Case Report

Abstract

Abstract Objectives Roux-en-y gastric bypass (RYGB) is a surgical procedure for weight loss via volume restriction and malabsorption. Without adequate postoperative nutrition, patients can develop micronutrient deficiencies. Methods A 48-year-old male with a history of RYGB nine years ago presented with lower extremity weakness. Patient lost over 150 lbs after surgery and did not consistently take vitamin supplementation. He reported worsening lower extremity weakness accompanied by paresthesias, swelling, and ataxia along with daily episodes of nausea and vomiting, constipation and incomplete bladder emptying. MRI showed signal abnormality of the dorsal columns and lateral corticospinal tracts of the cervical and thoracic spine concerning for copper deficiency. Vitamin testing found copper, vitamin B12 and methylmalonic acid levels to be normal, but vitamin E, thiamine and vitamin D levels were low. Patient was given oral vitamin supplementation with subsequent normalization of lab values; however, his neurologic symptoms did not improve. Results RYGB can cause significant vitamin deficiencies in the absence of adequate postoperative supplementation. Although patient's B12 and copper levels were normal at the time of testing, MRI and physical exam findings of hyperreflexia were most consistent a deficiency in either one (or both). Patient's ataxia (dry beriberi) and peripheral edema (wet beriberi) were also consistent with thiamine deficiency. Conclusions Micronutrient deficiencies are a preventable complication of RYGB, and patients should be regularly screened postoperatively. Although vitamin B12 and copper are the most common causes of nutrition-related myelopathy in the setting of bariatric surgery, vitamin E, thiamine and copper deficiencies are other potential causes to consider. Funding Sources N/A.