History Of Gastric Bypass Surgery Research Articles

Endoscopic shaving of hair in a gastric bypass patient with a large bezoar

Trichotillomania can be associated with the formation of trichobezoars (hair ball) usually located in the stomach. Trichobezoars may lead to complications including bowel obstruction, and perforation. Patients with a history...

A Case of Exogenous Lipoid Pneumonia: A Malignancy Mimicker

SESSION TITLE: Sarcoidosis and Cystic Lung Disease SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Exogenous lipoid pneumonia (ELP) is an uncommon form of aspiration pneumonia caused by aspiration of a fat-containing material. While rare, an early and correct diagnosis is important to decrease morbidity. We describe a case of ELP due to mineral oil aspiration CASE PRESENTATION: A 57-year-old male with history of gastric bypass surgery presented with incidental findings of lung infiltrates on abdominal CT. CT was done to assess for possible malignancy due to significant constitutional symptoms of weight loss, bone pain, muscle weakness, and recurrent falls. He chewed tobacco for 40 years and denied any respiratory symptoms. Vital signs and chest examination were unremarkable. Chest CT showed patchy bilateral centrilobular ground-glass opacities with lingular consolidation, that of fat density (-61 HU) on mediastinal views. Pulmonary testing and rheumatologic serologies were unrevealing. Bronchoalveolar lavage showed predominantly neutrophilic alveolitis (88%) with negative cytology and cultures. Transbronchial biopsy showed patchy foamy alveolar macrophage accumulation. Although the diagnosis was apparent, due to ongoing concerns for an underlying malignancy, he underwent a surgical lung biopsy that confirmed ELP. In retrospect, he reported ingesting mineral oil at bedtime for constipation DISCUSSION: The history of gastric bypass surgery and the timing of ingestion increased his risk for aspiration. ELP is often silent and chronic as oils do not provoke a strong swallow or cough reflex. Diagnosis is often delayed due to nonspecific clinical presentation and often with minimal respiratory symptoms disproportionate to the radiological findings. However, ELP can be suggested by characteristic ground-glass opacities and consolidation that is of fat attenuation in the right clinical context (i.e. exposure). A bronchoscopy can aid diagnosis with findings of lipid laden macrophages. Spontaneous resolution is expected in most with cessation of exposure. Other therapies include corticosteroids and whole lung lavage CONCLUSIONS: Exposure history is essential to facilitate a timely diagnosis of ELP. CT findings can range from ground-glass to consolidation, but it is important to view the consolidation in mediastinal windows. Bronchoscopy in the right clinical and radiographic context can help confirm the diagnosis and potentially avoid additional invasive procedures Reference #1: Marchiori E, Zanetti G, Mano CM, Hochhegger B. Exogenous lipoid pneumonia. Clinical and radiological manifestations. Respir Med 2011;105(5):659-666 DISCLOSURE: The following authors have nothing to disclose: Ali Zaied, Jack Leventhal No Product/Research Disclosure Information

A5088 - Title: A Case Study: Management of a bile leak after partial cholecystectomy in a patient status post Roux-en-Y gastric bypass surgery with a controlled choledochocutaneous fistula

In this case we will discuss post operative management of a patient who underwent a partial cholecystectomy secondary to acute gangrenous cholecystitis. This case is complicated by the fact the patient had a previous history of gastric bypass surgery, limiting the options of treatment of cystic duct leak post operatively. We will discuss the details of our patient, the complications of his procedure and the means by which we manage a bile leak when previous gastric bypass surgery prevents treatment by conventional treatment pathways. There are very few cases such as this in literature today, which calls for further investigation and research.

Undernutrition - Bariatric Athlete

HISTORY: A 38 year old female with past medical history of hypertension, hyperlipidemia, and obesity presented to the major medical tent by wheelchair with complaints of profound weakness and dizziness after having just completed a marathon. She described having run the majority of the marathon and had not sustained any injuries along the course. She described weakness and dizziness as mentioned in addition to “being dehydrated.” Review of systems was otherwise negative. Of note the patient also had a history of gastric bypass surgery 2 years prior to date of presentation. PHYSICAL EXAM: Examination of the patient revealed a pale appearing woman in no acute distress with dry mucous membranes. The patient was fully alert and oriented and had normal cardiac and respiratory exam. DIFFERENTIAL DIAGNOSIS: 1. Dehydration 2. Exertional Hyponatremia 3. Heat Related Illness TEST AND RESULTS: Vital Signs: Temperature 98.5F, Heart Rate 82, Blood Pressure 123/62 Labs: pH 7.45, pCO2 35.2, pO2 98, Na 141, K 4.6, HC03 24.7, BG 83, iCa 1.15 Hemoglobin/Hematocrit – 13.3/39 FINAL/WORKING DIAGNOSIS: Dehydration and Undernutrition TREATMENT AND OUTCOMES: 1. 1 liter bolus of normal saline administered intravenously through left AC IV line in addition to PO hydration with low calorie sports drink 2. Patient provided warming blankets for comfort in setting of cool outside temperature 3. The patient’s symptoms resolved and she felt significantly better within approximately 20 minutes of receiving normal saline bolus 4. The recommendation was provided to the patient to be evaluated by sports nutritionist with experience in caring for endurance athletes who have undergone bypass or weight loss surgery to assist with maintaining balanced nutrition and hydration while exercising.

Comorbidities, Concomitant Medications, and Diet as Factors Affecting Levothyroxine Therapy: Results of the CONTROL Surveillance Project.

BackgroundThe CONTROL Surveillance Project was a comprehensive patient-based survey conducted among hypothyroid patients undergoing treatment. The primary objective of the study was to specifically quantify the prevalence of factors adversely affecting levothyroxine therapy.MethodsParticipants were selected from a large proprietary database. Those eligible for the study completed a 21-question survey.ResultsOf the eligible hypothyroid patients, 925 (92.5 %) were being treated with levothyroxine monotherapy. The mean age was 60.4 years; 755 (81.6 %) were female and 168 (18.2 %) were male. Almost half of those receiving levothyroxine (435, 47.0 %) had at least one comorbid condition that could adversely affect its absorption: gastroesophageal reflux disease (33.8 % of patients), irritable bowel syndrome (9.7 %), lactose intolerance (7.8 %), or a history of gastric bypass surgery or bowel resection (3.0 %). Other factors reported by many patients that could adversely affect levothyroxine absorption included use of prescription medications (20.6 %) and over-the-counter medications (34.3 %) used to treat comorbid gastrointestinal (GI) conditions; use of dietary supplements (51.8 %, primarily calcium and iron); and intake of foods/beverages high in fiber, iodine, or soy (68.0 %). Of the 13.4 % who reported difficulty controlling their hypothyroid symptoms, significantly more patients with comorbid GI conditions reported such difficulty (7.8 versus 5.6 %, P < 0.01). Frequent changes in levothyroxine dosing (two or more dose changes in the past year) were reported by 8.0 % of survey participants. Those with GI comorbidities were nearly twice as likely to have such changes (5.0 versus 3.0 %, P < 0.01).ConclusionBetter initial workup of patients, including identification of relevant GI comorbidities and allergies, may help in the early detection of factors that may affect the performance of levothyroxine.

Operative Complications During Pregnancy After Gastric Bypass—a Register-Based Cohort Study

Late complications to bariatric surgery during pregnancy have become an area of concern. Expansion of the uterus and the following displacement of the small intestine may increase the risk of internal herniation. We wanted to estimate the risk and consequences of surgical complications during pregnancy in a national cohort of women with a history of gastric bypass surgery. A national, register-based cohort study of all Danish women with a history of gastric bypass surgery who had given birth from 2004 to 2010 was conducted. Surgical codes registered during pregnancy and until 120 days postpartum were identified in national registers, and the individual charts were reviewed in relevant cases. Of 286 women giving birth, fourteen women underwent procedures that might be related to the earlier gastric bypass surgery. Three women were operated on suspicion of internal herniation. In all three cases, mesenteric defects were found, and herniation was still present in two women, one of which died postoperatively. Five women were investigated by gastroscopy or sigmoidoscopy either during or after the delivery, and in six women cholecystectomy was performed during the puerperium. The incidence of internal herniation during pregnancy was 1 % in our study. Internal herniation may be a serious complication in pregnant women, and both the diagnosis and treatment requires handling by experienced obstetrical, radiological, and surgical staff.

Esophageal Inlet Patch: A Rare Cause of Melena

Purpose: Esophageal inlet patches are congenital anomalies of heterotopic gastric mucosa occurring in the proximal esophagus. They are infrequently seen, generally asymptomatic and typically do not warrant intervention. While rare complications may occur, there is only one documented case of bleeding from an inlet patch. We report an unusual case of melena resulting from an esophageal inlet patch. A 41-year-old woman with a past medical history of gastric bypass surgery was referred for evaluation of melena. She had a history of gastroesophageal reflux which was self-managed with intermittent antacids or over-the-counter lansoprazole. She denied nausea, vomiting, dysphagia, odynophagia, melena, and hematochezia. Her exam revealed stable vital signs, a benign abdomen with healed surgical scars and hemoccult positive stool. A colonoscopy revealed no abnormalities. An UGI with small bowel follow-through was normal. An EGD showed a 1-cm, irregular area of salmon-colored mucosa in the proximal esophagus with a central dark spot consistent with recent bleeding. No hemostatic intervention was required. Biopsies of the area revealed gastric mucosa with chronic inflammation. The gastric pouch, anastomosis, and small bowel mucosa was without abnormality. She was treated with omeprazole with resolution of her melena. There is limited available information in the literature on esophageal inlet patches. Endoscopy reveals salmon-colored mucosa distinct from the surrounding esophageal mucosa. Definitive diagnosis is made by histologic evaluation revealing gastric mucosa. Clinical manifestations are unusual, ranging from acid-related manifestations to dysplastic changes. The relationship with Helicobacter pylori is unclear. However, there has been only one previously reported case of bleeding associated with an inlet patch. This case illustrates the importance of careful endoscopic assessment and high level of suspicion in the appropriate clinical circumstances.

Acute Liver and Multi-organ Failure Secondary to Intentional Iron Overdose

Introduction: Intentional iron overdoses are rare in adults, but have severe consequences. We report two patients with multi-organ system failure occurring rapidly after large quantity oral iron ingestions. Case Discussion: A 26-year-old woman was transferred from an outside hospital (OSH) for acute liver failure (ALF): 48 hours prior, she had intentionally ingested a large amount of iron supplements. At initial presentation, she had nausea, gastrointestinal bleeding and normal liver enzyme levels. She then developed abdominal pain, tender hepatomegaly, elevated liver enzymes and coagulopathy (see table). No asterixis or encephalopathy was present. Deferoxamine, N-acetylcysteine (NAC) and dialysis were initiated. She progressed to coma, shock, brainstem herniation and death. Case B: A 35-year-old woman with prior gastric bypass surgery, hypertension, iron deficiency anemia and previous suicide attempt was transferred from an OSH with ALF after intentionally ingesting 300 iron pills the evening before. She developed nausea, vomiting, diarrhea and abdominal pain. Initially, she was hypertensive, had a tender abdomen, but no asterixis. Acute kidney injury (AKI) and severe acidosis were managed with intravenous fluids and, eventually, dialysis. She also received a proton pump inhibitor, NAC, polyethylene glycol laxative and deferoxamine. She recovered after 16 days, with liver enzymes and INR near normal. However, she remained dialysis-dependent on discharge, and subsequently has been lost to follow-up. Acetaminophen adducts were negative, and no radio-opaque pills were identified on abdominal x-ray (KUB) in either case. Discussion: Iron overdose causes rapid onset multi-organ failure with high mortality. Iron-induced oxidative damage results from hepatocyte exposure to high quantities of non-transferrin bound iron via the portal venous system, resulting in excessive free radical production. Peak serum iron levels occur 4-6 hours after ingestion. Bowel irrigation is indicated if tablets are identified on KUB. IV deferoxamine should be administered early if systemic signs such as metabolic acidosis are present. NAC can be given empirically. AKI is thought to be from direct mitochondrial injury and lactic acidosis. In case B, survival may, in part, have been due to the history of gastric bypass surgery, which may have limited absorption. These patients were enrolled in the Acute Liver Failure Study Group registry, supported by U-01-58369-014 from NIDDK.Table 5: Liver function tests

Reversible myeloneuropathy and pancytopenia related to copper deficiency from gastric bypass surgery: A case report

Introduction: Weight loss surgery has become an increasingly popular means of combating the obesity epidemic in modern society but like any procedure, it does not shy away from immediate and long-term complications. Copper deficiency has occasionally been reported to occur many years afterwards but with an increased incidence of bariatric procedures and reduced awareness, the effects of this deficiency could now appear to favor an earlier onset. Case Report: We report a case of a 56-year-old Caucasian female with a history of gastric bypass surgery five year ago; with an unsteady gait, weakness, decreased visual acuity, tingling with numbness in her hands and pancytopenia for the last month. She was treated for copper deficiency. Conclusion: Effects of copper deficiency have been shown to cause a wide array of abnormalities related to inactivation of enzymes such as cytochrome c oxidase, superoxide dismutase, dopamine beta hydroxylase and metallothionein. This can lead to reduced nerve transmission within the central nervous system causing motor and sensory polymyeloneuropathy and an overall reduction of energy required for blood cell formation. With early surveillance, such anomalies can be detected and potentially reverse the effects of this micronutrient deficiency.

Internal hernias in pregnant women with history of gastric bypass surgery: Case series and review of literature

INTRODUCTIONGastric bypass surgery is the most common obesity surgery procedure in women. Decreased weight loss favors fertility and leads to pregnancy sometimes just months after surgery, raising the risk of developing gastric bypass-related complications during pregnancy, including the formation of internal hernias. PRESENTATION OF CASEThe first patient presented at 37 weeks of gestation with abdominal pain, nausea and vomiting. X-ray revealed multiple air-fluid levels and absence of gas in colon. She underwent a cesarean section and exploratory laparotomy without complications. A Petersen's space internal hernia was found. The second patient presented at 25 weeks of gestation with abdominal pain and nausea. X-ray revealed multiple air–fluid levels and a “U-shaped” intestinal loop. She underwent exploratory laparotomy with reduction of an internal hernia also in Petersen's space. DISCUSSIONPregnant patients with internal hernias after gastric bypass are usually of young age and with a several-day history of abdominal pain. Surgical exploration is safe and should not be delayed. The literature review showed that maternal death (9%) and fetal death (13.6%) rates are considerably high. CONCLUSIONThe possibility of an internal hernia should always be considered in pregnant women with history of gastric bypass who present with abdominal pain, in order to prevent catastrophic outcomes such as maternal and/or fetal death.

Intussusception Status-Post Roux-En-Y Gastric Bypass

A 38-year-old female presented with acute onset epigastric abdominal pain and vomiting. Surgical history included gastric bypass surgery 8 years prior and cesarean delivery. The patient was in severe distress, afebrile, had significant epigastric tenderness with guarding, normal bowel sounds, and no distention or masses. Results for white blood cell count, serum chemistry panel, anion gap, urinalysis, liver function tests, lipase test, and plain radiographs were all normal; computed tomography (CT) of the abdomen/pelvis showed intussusception at the jejunojejunal anastomosis (Figure). The patient underwent resection of the affected bowel segment and had an uneventful recovery. Roux-en-Y gastric bypass (RYGB) is the most common surgical treatment of morbid obesity in the United States.1–5 The frequency of small-bowel obstruction after laparoscopic RYGB is between 0.2% to 4.5% and can occur months to years after the procedure.1,5 Small-bowel obstruction in these patients is usually caused by adhesions, internal hernias, and rarely, intussusception.1–5 Intussusception must be considered because ischemia and necrosis of the affected bowel segment can occur.5 Clinical presentation can be acute or subacute (recurrent vague abdominal pain) and is variable (most patients do not appear ill). The most common presentation is vague abdominal pain, nausea, and vomiting.4 Severity of pain is usually out of proportion to physical examination. Lack of obstruction symptoms does not rule out intussusception. Findings on plain radiographs are often negative.1,5 CT of the abdomen and pelvis (oral and intravenous contrast) is the diagnostic test of choice, with an accuracy of 80%. Pathognomonic findings include a “target sign” (Figure).5 Patients with a history of gastric bypass surgery, persistent abdominal pain, and a negative CT finding still require surgical evaluation and possibly surgical exploration.1,5 Blind nasogastric tube placement can lead to perforation at the gastrojejunostomy.1 Treatment is surgical intervention, usually with resection of the affected bowel segment and reconstruction of a new jejunojejunostomy distally.1 Recurrences can occur after surgical repair.1

Copper Deficiency: A Forgotten Disorder?

Abstract 5275 Background: Copper is an essential trace element that is required for the function of a number of enzymes necessary for normal metabolic activities including ferroxidase I (ceruloplasmin) which functions to release iron from cells with mobilizable iron stores. Copper deficiency is well reported in the literature but is considered relatively rare. It appears primarily to result from poor absorption, even though the precise mechanism(s) may not be apparent in all cases. Importantly, copper deficiency is a masquerader. It frequently results in manifestations that could easily be mistaken for another condition leading potentially to misdiagnosis and inappropriate therapy. Unlike vitamin B12 and folate deficiencies however, many guidelines and textbooks make no mention of copper deficiency as a potential secondary cause for a myelodysplasia (MDS)-like presentation or neuropathy even though multiple reports have described these associations. Methods and Results: In order to formally explore physician awareness about copper deficiency at our own institution we reviewed the medical records of 46 patients that were referred to the department of Hematology and/or Neurology at the Louisville Veterans Affairs Medical Center by their primary care physicians during the year 2010. 23 (49%) and 24 (51%) patients were referred for cytopenia (s) / macrocytosis and/or peripheral neuropathy respectively. however; no clearly identifiable etiology was found. Among patients with cytopenia (s) / macrocytosis, 34.8% (n=8) had concomitant peripheral neuropathy, 91.3% (n=21) presented with anemia as a part of their cytopenia (s); of those, 43% (n=9) were deficient in Iron without any clear etiology and 8.7% (n=2) were diagnosed with myelodysplatic syndrome. 100% (23) of patients with cytopenia (s)/macrocytosis were evaluated for Folic Acid and B12 deficiency either by their Primary care physician or hematologist. Only two patients (8.7%) were diagnosed with B12 deficiency, of those, one (4.3%) was referred because of isolated macrocytosis with a normal serum copper level checked by the hematologist. 100% (n=24) of patients referred to the neurology clinic with peripheral neuropathy were evaluated for Folic Acid and B12 deficiency, all with normal results. However, none were evaluated for copper deficiency including one patient with a history of gastric bypass surgery. Among these patients, 47.8% (n=11) were identified with isolated peripheral neuropathy, 8.3% with concomitant anemia, 8.3% with thrombocytopenia, 33.3% (n=8) with diabetes mellitus or impaired glucose tolerance test, 12.5% (n=3) with a history of alcohol abuse, 4.2% (n=1) with a positive HIV test and 4.2% (n=1) with a history of gastric bypass surgery with concomitant thrombocytopenia. Conclusion: Our study albeit small and from a single institution points to a significant lack of awareness among physicians about copper deficiency as a possible diagnostic consideration in patients with cytopenias and/or neuropathy even though it has been clearly reported in the literature to be associated with a clinical presentation very similar to B12 deficiency. We believe that this is representative of the prevailing practice pattern in the medical community as a whole. It is understandable therefore that we do not really know the true incidence of a disorder that is rarely tested even in patients presenting with known clinical features associated with it. Finally, one of the most compelling reasons to recognize copper deficiency is that like B12 deficiency, this is a potentially devastating condition that is treatable with simple replacement therapy. Disclaimer: The contents of this abstract do not represent the views of the Department of Veterans Affairs or the US government. Disclosures: No relevant conflicts of interest to declare.

Hedonic hunger is increased in severely obese patients and is reduced after gastric bypass surgery

Overeating as a pathogenetic hallmark of obesity may be promoted by an increase in hedonic hunger, ie, the drive to eat palatable foods in the absence of energy need. Gastric bypass surgery, which effectively reduces severe obesity, might also affect hedonic hunger. The objective was to assess hedonic hunger in severely obese patients with and without a history of gastric bypass surgery. Severely obese patients who had not undergone gastric bypass surgery (n = 123), gastric bypass patients (n = 136), and nonobese control subjects (n = 110) were examined with the Power of Food Scale (PFS)--a questionnaire that reliably measures an individual's motivation to consume highly palatable foods. Compared with nonobese control subjects, severely obese patients achieved markedly higher aggregated PFS scores and subdomain scores related to generally available as well as physically present foods (all P < 0.001). On the aggregated score as well in those 2 subdomains, gastric bypass patients scored significantly lower than did non-gastric bypass obese patients (all P < 0.001) and did not differ significantly from the nonobese control group (P > 0.2). In contrast, in the PFS domain concerning food tasted, gastric bypass patients had significantly lower scores than did the nonobese control subjects (P = 0.04) and the severely obese patients (P = 0.008), both of whom did not differ significantly in this measure (P = 0.90). In comparison with nonobese control subjects, severely obese patients display a marked increase in hedonic hunger that is not observed in patients who have undergone gastric bypass surgery, suggesting that the operation normalizes excessive appetite for palatable foods, which may be an important pathophysiologic feature of severe obesity.

Spontaneous Large Intramural Hematoma in Roux Limb of Gastric Bypass

Purpose: Abdominal pain with a significant hematocrit drop may indicate severe GI bleeding. However, if there is no hematemesis, melena or hematochezia, bleeding from other sources must be considered. We describe a previously unreported case of spontaneous intramural bleeding within the Roux limb in a patient with a history of gastric bypass surgery. Methods: A 34 year old woman, 13 days post bone marrow transplant for acute myeloid leukemia, with a history of Roux-en-Y gastric bypass surgery 2 years prior, developed moderate abdominal pain with Hct 28%, WBC 0.03 K/μL and platelets 6 K/μL. Esomeprazole and sucralfate were initiated, which did not relieve the pain. Over the next 3 days, the Hct dropped from 28% to 15%. The patient had more abdominal pain, tachycardia and hypotension. She had nausea, but no vomiting or hematemesis. She had regular bowel movements, no melena or hematochezia. After resuscitation with fluid, blood and platelet transfusions, the patient underwent an abdominal CT scan. Results: On CT scan, there was an extensive intramural hematoma confined within the Roux limb of the gastric bypass with a wall thickness measuring up to 1.7 cm. The abnormality extended from the gastrojejunostomy to within a few centimeters of the jejunojejunostomy. The patient was given blood and platelet transfusions to maintain the Hct at 30% and platelet at 50 K/μL. The bleeding gradually stopped over a week. The patient's symptoms of abdominal pain and nausea resolved. A repeat CT scan one month later demonstrated complete resolution of the intramural hematoma from the Roux limb. Conclusion: Spontaneous intramural small bowel wall hematoma has been reported in patients with excessive anticoagulation or with other risk factors for bleeding. The jejunum is the most common site of the hematoma, followed by the ileum and duodenum. Abdominal CT scan is the diagnostic modality of choice to detect an intramural hematoma. CT scan findings include circumferential or asymmetric wall thickening, intramural hyperdensity, luminal narrowing, and intestinal obstruction. Accurate diagnosis is crucial because most patients can be treated nonoperatively with a good outcome. Resolution of the hematoma can be seen as early as 1 week after onset. In our case, the risk factor for bleeding was the extremely low platelet count. The patient responded well to conservative management. This is the first reported case of spontaneous intramural bleeding in the entire Roux limb of a gastric bypass.

Laparoscopic Management of Splenic Artery Aneurysms

Splenic artery aneurysms are rare clinical entities that carry the risk of rupture and fatal hemorrhage. Due to the availability of advanced imaging techniques, they are now being found more frequently and identified earlier. Historically, the surgical approach to their management has consisted of laparotomy with resection of the aneurysm and a possible splenectomy. Recently, angiographic interventions and laparoscopic exclusion of splenic artery aneurysm has been shown to provide adequate therapy without the morbidity associated with open aneurysmectomy and splenectomy. In patients with previous abdominal surgery, a planned hand-assisted approach may be needed. We present the cases of two patients with splenic artery aneurysms who were successfully managed laparoscopically. The hand-assisted approach was needed in our second patient, who had a history of gastric bypass surgery. Both patients had an uneventful postoperative course and were discharged home on postoperative day one.

B-Type Natriuretic Peptide (BNP) and N-Terminal Pro-BNP in Obese Patients without Heart Failure: Relationship to Body Mass Index and Gastric Bypass Surgery

Further investigations are warranted to better characterize variables that may confound the clinical interpretation of plasma natriuretic peptide measurements, which are increasingly recognized to have diagnostic and predictive importance. Blood samples (EDTA plasma) from patients (n = 206) attending clinics for the medical treatment and follow-up of obesity were analyzed for B-type natriuretic peptide (BNP; Bayer assay) and the N-terminal segment of its prohormone (NT-proBNP; Roche assay). Natriuretic peptide concentration ranges were evaluated in those without diagnosis of congestive heart failure (CHF) or chronic kidney disease (CKD). BNP and NT-proBNP were directly correlated (r = 0.87; P = 0.01), with NT-proBNP concentrations higher relative to BNP. Of obese patients without CHF or CKD, 21.6% (40 of 185) had NT-proBNP concentrations greater than the published assay upper reference limit. Concentrations of both natriuretic peptides were higher in patients currently exposed to beta blockers, patients with the diagnosis of hypertension or type 2 diabetes, and patients with a history of gastric bypass surgery. An inverse relationship between body mass index (BMI) and both BNP and NT-proBNP was evident. According to the National Institutes of Health, National Heart, Lung, and Blood Institute classification, more than 95% of the participants sampled in this study were either obesity class 2 (35 kg/m(2) < BMI < 39.9 kg/m(2)) or class 3 (BMI >or=40 kg/m(2)) A substantial proportion of obese patients without CHF or CKD have concentrations greater than the upper reference limit for NT-proBNP but not for simultaneously measured BNP. A history of gastric bypass surgery appeared to be a significant predictor of increased natriuretic peptide concentrations when assessed in a population of patients with class 2 or 3 obesity.

WERNICKE'S ENCEPHALOPATHY IN A PATIENT AFTER GASTRIC BYPASS SURGERY

INTRODUCTION: Obesity is a major public health crisis. There were approximately 414,000 deaths attributed to obesity in 2000.1 Bariatric surgery for morbid obesity has become more common as a result of the increasing prevalence of obesity. There are many complications that can occur related to bariatric surgery; however, malnutrition and essential vitamin deficiencies are not commonly recognized. We present a case of Wernicke's encephalopathy most likely secondary to thiamine deficiency in a patient who had a recent history of gastric bypass surgery.

Pregnancy After Gastric Bypass Surgery and Internal Hernia Formation

Gastric bypass is a surgical procedure that is increasingly performed in the United States to treat morbid obesity. Because of the changes associated with pregnancy, women with a history of gastric bypass surgery may be at an increased risk of gastrointestinal complications during the antepartum period, as demonstrated by these cases. The first patient presented at 12 weeks of gestation with abdominal pain. Computed tomography scan revealed rotation of the small bowel mesentery. In the operating room, a Petersen's internal hernia was observed. The second patient presented at 34 weeks of gestation with epigastric pain, nausea, and vomiting. An abdominal computed tomography scan suggested distention of the biliopancreatic limb, duodenum, and bypassed stomach. She underwent exploratory laparotomy with repair of an internal (mesenteric loop) hernia. As obstetricians, we should be aware of the potential for internal hernias in pregnant patients who have undergone bariatric surgery.