Malabsorption Of Vitamin Research Articles

Prevalence of Bone Demineralization in AfroCaribbeans with Inflammatory Bowel Disease

Purpose: Osteoporosis/osteopenia has been increasingly recognized as a disease process concurrent with inflammatory bowel disease (IBD). Several inciting factors include malabsorption of Vitamin D and calcium, corticosteroid therapy, inflammatory cytokines, and smoking. Racial variation of osteoporosis in IBD patients has been poorly described. We sought to identify risk factors for bone demineralization in AfroCaribbean (AC) with IBD. Methods: A retrospective chart review was performed from a 10-year-old prospectively collected database of IBD patients (age >18 years) seen at a large urban university medical center. Data on dual energy X-ray absorptiometry (DXA) scanning, use of steroids, bisphosphonates, calcium, and vitamin D, as well as blood chemistries were collected and analyzed using the student's t-test and chi-square test as appropriate. Results: 115 charts of AC IBD patients [37 Crohn's disease (CD), 2 indeterminate colitis, 76 ulcerative colitis (UC)] were reviewed of which 24 patients (14 UC, 10 CD) had DXA scanning performed.10 patients had T-scores > -1, 14 patients had scores of < -1 of which 6 patients had scores <-2.5. 14 patients with a T-score of < -1 (mean age of 51 years, SD +/-20.4) were compared to ten patients with DXA scores > -1 (mean age 50.1 years, SD +/-14.9).Two patients with T-scores <-1 had fractures while none were observed in the comparison group (p=0.5). Mean body mass index (BMI) for those with T-scores <-1 was 23.9 kg/m2 compared to 31.5 kg/m2 in those with T-scores >-1 (p=0.0034). Two thirds of the patients with lower T-scores were prescribed treatment. See Table 1 for results. Conclusion: Screening for bone demineralization in ethnic populations with IBD is lacking as only 21% of AC IBD patients seen in our institution had a DXA scan. Of those who were scanned, more than half of the patients had T-scores suggestive of bone demineralization. Although elevated BMI was protective against demineralization in AC patients with IBD, these results should prompt further studies to determine the prevalence and significance of bone demineralization in minority populations with IBD.Table

Coeliac disease: clinical features in adult populations

coeliac disease (CD) is a chronic disease of the small intestine, which is caused by gluten intolerance, producing malabsorption of nutrients and vitamins. Clinical manifestations of CD in adults are highly variable, including intestinal and extra-intestinal symptoms. The disease may also occur in individuals who are asymptomatic. our objective is to describe the incidence and clinical manifestations of CD in adults. a retrospective study was carried out in patients diagnosed of CD between January 1990 and December 2008. Diagnosis was based on serologic tests and duodenal biopsy, which were compatible with CD in all of them. sixty eight adult patients were diagnosed of CD in this period. Mean age was 33 (18-65) years and 50 (74%) were women. The clinical manifestations were diarrhoea in 38 (55%), abdominal pain in 27 (40%), loss of weight in 15 (22%), dyspepsia in 13 (19%). Analytical results showed a slight increase of transaminases in 26 (38%), ferropenic anaemia in 33 (48.5%) cases, sub-clinical hypothyroidism in 3 (4.5%) patients, and folic acid deficiency in 16 (23.5%) cases. Almost all patients were diagnosed between 2000 and 2008: 60 (87%). Population-based incidence of CD in adults had increased from 0.7-2/100,000 per year in the nineties to 3.5-10.3/100,000 in the last years. CD can appear at any age and with a wide manifestation spectrum, which can be atypical in some cases. Patients with ferropenic anaemia and a negative response to treatment or those with an unexplained increase in transaminases should be screening for CD. Atypical manifestations and low suspect index can delay diagnosis even during years. There is a marked increase in the incidence-rates of CD in adults over time.

Alteraciones del metabolismo óseo en la cirugía bariátrica

Obesity is an ever-increasing disease in our environment, and a major risk factor for the development of other chronic diseases that increase morbidity and mortality. Bariatric surgery is an effective treatment for obesity, since it not only allows a significant and sustained loss of weight, but also an important reduction of its co-morbidities. However, this treatment is not free of complications, since along with weight loss, frequent nutritional and metabolic deficiencies have been described. These complications are particularly frequent when mixed surgical procedures with a restrictive and malabsortive component such as Roux-en-Y gastric bypass and biliopancreatic diversion are performed. The nutritional deficiencies observed include, to a greater or lesser extent, malabsorption of fat and liposoluble vitamins, as well as other micronutrients such as calcium. As a result, disorders of bone mineral metabolism with skeletal manifestations that include bone mass reduction, increased bone turnover and defective bone mineralization may develop.

The Improvement of Sensory Quality and Texture Properties of Gluten Free Bread Fortified with Ca

Celiac disease is a gluten-sensitive entheropathy. Later studies suggest an increasing prevalence of that disease, likely due to the development of more sensitive methods of screening. Cereals containing prolamins such as wheat, rye, barley, and oat are toxic for celiac patients, whereas corn, rice, sorghum and buckwheat are considered to be safe. The reaction to gluten ingestion by patients suffering from that chronic disease is inflammation of the small intestine leading to the malabsorption of several important nutrients, vitamins and minerals, especially of calcium and iron. Osteopenia and osteoporosis are a frequent complication accompanying coeliac disease. The only effective treatment for coeliac disease is a long-life strict adherence to a gluten-free diet. Up to now, research studies related to gluten free bakery products have been focused on the design of gluten free matrixes by combining different starches and gluten free cereals. However, no special attention has been paid to the use of those products as carriers or vehicles of micronutrients, which are necessary for celiac patients. The aim of the research was to design of gluten free formula fortified with calcium destined to bake a bread. In that order the available organic or mineral calcium supplements were analysed. Optimisation of the technological parameters, analysis of chemical and minerals composition, sensory quality and texture of bread crumb were analysed. Preliminary estimation of bread colour, odour and taste allowed to select calcium caseinate and calcium citrate as supplements affecting beneficially the sensory quality of bread. When the mixture of both of them was applied, the improvement of bread porosity and structure was also observed. Based on the sensory evaluation of bread carried out with the method of sensory profiling and in hedonic tests gluten free bread fortified with a mixture of calcium caseinate and citrate was selected as the best. Texture properties of fresh gluten free bread crumbs fortified with calcium supplements measured using compression device of Instron were considerably improved. Summarising, the application of calcium supplements such as calcium caseinate and citrate in order to fortified gluten free bread with calcium influence beneficially its sensory and nutritional properties simultaneously enhancing the structure and texture of bread.

Exocrine Pancreatic Insufficiency, Dyserythropoeitic Anemia, and Calvarial Hyperostosis Are Caused by a Mutation in the COX4I2 Gene

Steatorrhea and malabsorption of lipid-soluble vitamins due to exocrine pancreatic insufficiency are common in patients with cystic fibrosis and are predominant in Shwachman-Bodian-Diamond, Pearson, and Johanson-Blizzard syndromes. In four patients who suffered from congenital exocrine pancreatic insufficiency, dyserythropoeitic anemia, and calvarial hyperostosis, we excluded these disorders and identified, by using homozygosity mapping, a mutation in the COX4I2 gene. The COX4 protein is an essential structural subunit of cytochrome c oxidase complex and has two isoforms, encoded by two different genes. We show that the ratio of COX4I2 to COX4I1 mRNA is relatively high in human acinar cells. The mutation is associated with marked reduction of COX4I2 expression and with striking attenuation of the physiologic COX4I2 response to hypoxia. Mutation analysis of COX4I2 is warranted in patients with malabsorption due to exocrine pancreatic insufficiency and in patients with dyserythropoeitic anemia.

Is it time for vitamin B-12 fortification? What are the questions?

Since the introduction of folic acid fortification of flour 10 y ago, an initiative to consider fortifying flour with vitamin B-12 has gained momentum in the United States. The impetus for this move stems from several considerations, including some evidence that a proportion of neural tube defect pregnancies may be the result of vitamin B-12 rather than folate deficiency. However, no interventional trials have taken place to show the efficacy of vitamin B-12 supplementation or fortification in the primary prevention or recurrence of neural tube defect pregnancies, as was the case with folic acid. Other reasons put forward for the institution of vitamin B-12 fortification include the high prevalence of vitamin B-12 deficiency in certain demographic groups, including the elderly and the young in some countries. Much of this deficiency, however, is subclinical and not associated with manifest morbidity. Moreover, individuals affected by the most severe cases of vitamin B-12 deficiency that are associated with morbidity would not benefit from the concentrations of vitamin B-12 fortification that are practical or that are being considered, because such individuals suffer from malabsorption of vitamin B-12 rather than from an inadequacy of intake of the vitamin. In addition to the well-recognized complications of vitamin B-12 deficiency, such as macrocytic anemia and neurological complications affecting sensory and motor function, more subtle effects have also been described, including osteopenia, neurocognitive impairment, and increased vascular disease risk associated with elevated homocysteine. This analysis focuses on the research questions that are pertinent to the consideration of whether or not to introduce mandatory vitamin B-12 fortification in the United States.

Serum zinc in small children with coeliac disease

In coeliac disease (CD) there is a gluten-induced small bowel enteropathy leading to malabsorption of various nutrients, vitamins and trace elements. Low levels of serum zinc have been reported in adults with untreated CD. In the present study we related the serum concentration of zinc to the morphology of the small bowel mucosa in 58 children, all under 4 years of age and under investigation for coeliac disease. The mean serum concentration of zinc (mean +/- SD; mumol/L) was significantly lower in children with untreated CD (9.7 +/- 2.0) (n = 11) compared to non-coeliac children without enteropathy (15.1 +/- 2.3) (n = 16) (p < 0.001), coeliac children on a gluten-free diet without enteropathy (14.2 +/- 1.6) (n = 14) (p < 0.001), coeliac children on gluten challenge with enteropathy (14.1 +/- 2.1) (n = 12) (p < 0.001) and coeliac children on gluten challenge without enteropathy (13.8 +/- 1.9) (n = 6) (p < 0.005). Serum zinc concentration is decreased in untreated coeliac children with enteropathy and normalizes on gluten-free diet. A low serum zinc value in a child being investigated for possible CD on clinical grounds can thus be used as a complementary marker for enteropathy indicating further investigation with small bowel biopsy. The hypothetical role of zinc in the pathogenesis of CD is discussed.

Occurrence of Metabolic Osteopathy in Patients with Chronic Pancreatitis

Introduction: Chronic pancreatitis is an inflammatory disease manifested by maldigestion and, in an advanced stage, by malabsorption. The aim of our research was to monitor the occurrence of metabolic osteopathies (osteopenia, osteoporosis and osteomalacia) in patients with chronic pancreatitis. Patients and Methods: The group consisted of 73 patients (17 women and 56 men) in different stages of chronic pancreatitis. In all patients we determined serum concentrations of Ca, P, 25-OH vitamin D, 1,25-(OH)2 vitamin D, alkaline phosphatase and its bone isoenzyme. Bone mineral density was measured by dual-energy X-ray absorptiometry (DXA) in the lumbar spine (U-U) and in the proximal femur. When bone pathology was identified by DXA, we determined the other to exclude other causes of secondary osteopathy and the 24-hour loss of calcium and phosphorus in the urine. Results: Osteopathy was found in 39% of patients, i.e. osteopenia in 26%, osteoporosis in 5% and osteomalacia in 8% of cases. Conclusion: The occurrence of relatively high percentages of metabolic osteopathies in patients with chronic pancreatitis may correlate, namely in advanced stages of the disease, with the malabsorption of vitamin D to the enterohepatic circulation. In initial forms of pancreatitis, it is not possible to exclude pro- gression of osteopathy due to changes of the intestinal flora, with disturbance of vitamin D absorption to the intestinal mucosa.

Anemia of chronic disease and defective erythropoietin production in patients with celiac disease

Anemia due to hematinic deficiencies is common in patients with untreated celiac disease. Although celiac disease is a chronic condition characterized by an intense inflammatory response of the intestinal mucosa, scant data are available about the prevalence of anemia of chronic disease in celiac disease. One hundred and fifty-two patients with celiac disease at presentation were studied. Anemia was investigated by determining complete blood counts, body iron status, serum levels of the soluble transferrin receptor, erythropoietin, prohepcidin and interferon-gamma. Genotyping for HFE mutations associated with hereditary hemochromatosis was performed. Fifty-three anemic patients were re-evaluated for hematologic response after 1 year on a gluten-free diet. At the time of diagnosis of celiac disease the prevalence of anemia was 34%. Fifty-three out of 65 anemic patients had either iron and/or vitamin deficiency (folate, vitamin B(12)). Hereditary hemochromatosis mutations did not affect the prevalence of anemia. In 11 cases iron status parameters were indicative of anemia of chronic disease, sometimes in association with iron deficiency (6 patients). Patients with anemia of chronic disease had low levels of erythropoietin for the degree of anemia and increased serum interferon-gamma. In most cases anemia improved following a gluten-free diet, response rates being similar in anemia of chronic disease and in anemia due to hematinic deficiencies. Our study shows that, in addition to iron and vitamin deficiencies, anemia of chronic disease has a significant role in some patients with celiac disease. Suppression of intestinal inflammatory changes as a result of a gluten-free diet improves anemia by correcting iron and vitamin malabsorption as well as mechanisms contributing to anemia of chronic disease.

Vitamin K deficiency bleeding (VKDB) in early infancy

Vitamin K deficiency bleeding (VKDB) is a rare and potentially life-threatening bleeding disorder of early infancy. Vitamin K stores are low at birth; thereafter breast-fed infants are at risk because of low concentrations in human milk. Classical VKDB occurs in the first week of life, is related to delayed or inadequate feeding and is readily prevented by small doses of vitamin K at birth. Late VKDB peaks at 3-8 weeks, typically presents with intracranial haemorrhage often due to undiagnosed cholestasis with resultant malabsorption of vitamin K. Diagnosis can be difficult but PIVKA-II measurements can provide confirmation even several days post-treatment. Without vitamin K prophylaxis, the incidence of late VKDB in Europe is 4-7 cases per 10(5) births; it is higher in SE Asia where in rural, low-income areas some 0.1% of affected infants may suffer intracranial bleeding. Late VKDB is largely preventable with parenteral vitamin K providing the best protection. The efficacy of oral prophylaxis is related to the dose and frequency of administration. Most multi-dose oral regimens provide protection for all except a small reservoir of infants with undetected hepatobiliary disease. Targeted surveillance of high-risk groups (e.g. biliary atresia) offers a novel approach to assess efficacy of prophylaxis.

Calcium, Parathormone, and Vitamin D Abnormalities among Roux-en-Y Gastric Bypass Patients

Background: Malabsorption of vitamin D and calcium is a known side effect of laparoscopic gastric bypass (LGB). Our objective was to identify the prevalence of abnormalities in calcium, parathormone (PTH), and 25-OH vitamin D levels in patients undergoing LGB, and the correlation of reported compliance with supplementation, and seasonal variation on vitamin D levels. Methods: Patients undergoing LGB from September 2003 through June 2004 were included. Calcium and PTH levels were obtained preoperatively. At 1 year postoperatively, calcium, PTH, and vitamin D levels were obtained. Laboratory values were classified as low, normal, or high, based on standard reference ranges. Results were analyzed using the exact binomial test. Results: One-year follow-up laboratory data were available for 70 patients: 10 males and 60 females with a mean age of 44.7 years. The mean preoperative body mass index was 47.4 kg/m2. Mean percent excess weight loss at 1 year was 73.4%. Nine patients (14.3%) had elevated PTH levels preoperatively, and seven patients (10.3%) had elevated PTH postoperatively (p ≤ 0.001). The incidence of low 25-OH vitamin D levels postoperatively was 40.4%. Conclusions: A significant percentage of patients undergoing LGB present with an abnormally high PTH level. Abnormally low vitamin D levels are quite prevalent 1 year after LGB, despite normal serum calcium levels. The month of surgery (summer vs. winter) did not have an impact on PTH, calcium, or vitamin D levels. Patients' self-reported compliance or noncompliance with recommended supplementation did not correlate with their vitamin D levels.

Refractory Hypocalcemia Following Near-Total Thyroidectomy in a Patient with a Prior Roux-en-Y Gastric Bypass

Patients undergoing malabsorptive weight-loss procedures are at increased risk of calcium and vitamin D deficiency. Thyroidectomy carries the risk of both immediate and long-term hypocalcemia. Here we describe a patient who underwent Roux-en-Y gastric bypass (RYGB) and subsequent near-total thyroidectomy and then developed refractory hypocalcemia. Serum calcium reached a nadir of 6.1 mg/dl despite aggressive therapy with oral and IV calcium, calcitriol (1,25(OH)(2)D(3)), and IV magnesium sulfate. One year later, the patient has permanent hypoparathyroidism and requires very high doses of calcium, vitamin D, and calcitriol to prevent symptomatic hypocalcemia. Providers should be aware that malabsorption of calcium and vitamin D after RYGB may complicate patient management after thyroidectomy.

PL-22: Elevated parathyroid hormone is not a marker for preoperative bone loss in morbidly obese women presenting for gastric bypass

Parathyroid hormone (Pth) maintains calcium homeostasis in hypovitaminosis D by resorption of calcium from bone. 30.2% of patients (pts) presenting for gastric bypass have secondary hyperparathyroidism, and are at risk of osteopenia after surgery due to malabsorption of vitamin D (Vit D) and calcium (Ca). Because hyperparathyroidism has deleterious effects on bone, we evaluated patients with elevated preoperative Pth levels for preoperative bone loss.

Clinical and Etiological Profile of Tropical Ataxic Neuropathy in Kerala, South India

Background/Aims: Very little is known about the occurrence of tropical ataxic neuropathy (TAN) from southern India. This study describes the clinical spectrum of TAN from Kerala, southern India, and explores its etiology. Methods: We reviewed the clinical and laboratory profile of 40 TAN cases diagnosed in a tertiary referral center in central Kerala. We enquired the consumption of cassava foods and estimated the thiocyanate levels in the serum, urine and sural nerve. Results: The notable demographic characteristics included female preponderance, peak age at onset in the thirties, rural residence and poor socioeconomic status. The diet in the majority comprised a large amount of tapioca, which is low in protein. In addition to sensory peripheral neuropathy, 90% had decreased hearing, 50% had decreased vision, and 25% had spasticity involving the lower extremities. None had signs of overt vitamin deficiencies or malabsorption syndrome. Compared to the controls, the serum, urine and sural nerve thiocyanate levels were significantly elevated in the patients. With cessation of cassavaintake and better nutrition, improvement in the neurological disability occurred in the majority. Conclusions: This study, for the first time, provides evidence for the occurrence of TAN in south India and the possible etiological role of cassava intake.

Abetalipoproteinemia

A 13-month-old Filipino boy presented with an 11-month history of emesis, diarrhea, hepatomegaly, wasted extremities, and growth failure. The diarrhea improved with fasting. The patient had mildly elevated serum transaminases with an SGOT of 93 IU/L and an SGPT of 55 IU/L. Liver biopsy revealed marked macrosteatosis and microvesicular steatosis. Serum albumin, triglyceride, and cholesterol levels were undetectable. Tissue transglutaminase titer, fecal elastase, fecal α1-antitrypsin levels, and transferrin electrophoresis were normal. Upper endoscopy was grossly unremarkable, but duodenal biopsies revealed prominent vacuolization of the surface epithelium consistent with a storage or transport defect (Fig. 1). Electron microscopy demonstrated large lipid droplets throughout the enterocyte cytoplasm (Fig. 2). Based on these results, the patient was diagnosed with abetalipoproteinemia. He improved with good weight gain and resolution of diarrhea on a low-fat diet with fat-soluble vitamin supplementation and parenteral nutrition.FIG. 1: Standard hematoxylin and eosin staining demonstrating accumulation of clear material in the enterocyte cytoplasm (arrow; original magnification ×100).FIG. 2: Electron microscopy demonstrating lipid droplets throughout the cytoplasm characteristic of abetalipoproteinemia (arrow).Abetalipoproteinemia occurs in infancy and presents with hypocholesterolemia and hypotriglyceridemia as well as diarrhea and growth failure due to an absence of apo B lipoproteins. Symptoms consistent with fat-soluble vitamin malabsorption (eg, retinitis pigmentosa, neurological abnormalities) are common (1). Biopsies reveal lipid droplets contained in the enterocyte due to their lack of transport to the Golgi apparatus (2). Electron microscopy is essential to demonstrate lipid accumulation in enterocytes in such patients. Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at www.jpgn.org, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal.

Neonatal Short Bowel Syndrome

Short bowel syndrome is a complex state of malabsorption and malnutrition resulting from massive intestinal resection. After resection, the remaining intestine undergoes a process of adaptation in an effort to replace lost intestinal function. Complications from short bowel syndrome include severe diarrhea; vitamin and nutrient malabsorption; and increased risks of sepsis, central line complications, and development of liver disease. Treatment is primarily supportive and focuses on enhancing the adaptation process and optimization of growth. In cases of extremely short bowel length, poor adaptation, and/or development of life-threatening complications, organ transplantation may be the best option for treatment.

Inborn Errors of Bile Acid Metabolism

Bile acids are synthesized by the liver from cholesterol through a complex series of reactions involving at least 14 enzymatic steps. A failure to perform any of these reactions will block bile acid production with failure to produce "normal bile acids" and, instead, result in the accumulation of unusual bile acids and intermediary metabolites. Failure to synthesize bile acids leads to reduced bile flow and decreased intraluminal solubilization of fat and fat-soluble vitamins. In some circumstances, the intermediates created because of blockade in the bile acid biosynthetic pathway may be toxic to hepatocytes. Nine recognized inborn errors of bile acid metabolism have been identified that lead to enzyme deficiencies and impaired bile acid synthesis in infants, children, and adults. Patients may present with neonatal cholestasis, neurologic disease, or fat and fat-soluble vitamin malabsorption. If untreated, progressive liver disease may develop or reduced intestinal bile acid concentrations may lead to serious morbidity or mortality. This review focuses on a description of the disorders of bile acid synthesis that are directly related to single defects in the metabolic pathway, their proposed pathogenesis, treatment, and prognosis.

Elevated Homocysteine Levels in Patients with Slow Coronary Flow: Relationship with Helicobacter pylori Infection

Elevation of plasma homocysteine (Hcy) level has been implicated in the pathogenesis of slow coronary flow (SCF) as it can severely disturb vascular endothelial function. Helicobacter pylori chronically infect the human stomach and causes malabsorption of vitamin B(12) and folate in food, leading ultimately to an increase in circulating Hcy levels. Forty-three patients with angiographically proven SCF (group I) were enrolled in this study; 43 cases with normal coronary flow pattern (group II) served as controls. Fasting plasma levels of Hcy, vitamin B(12), and folate were measured in all subjects. Presence of H. pylori infection was defined as positive 14 C urea breath test. Coronary flow patterns for each major epicardial coronary artery were determined with the Thrombolysis in Myocardial Infarction (TIMI) frame count method. Mean TIMI frame count was 46.3 +/- 8.7 in group I and 24.3 +/- 2.9 in Group II (p = .0001). Vitamin B(12) levels were similar, whereas folate levels were dramatically reduced in group I compared to group II (13.2 +/- 4.3 vs. 17.1 +/- 5.2, p = .0001). Plasma Hcy levels were significantly higher in group I compared to group II (13.4 +/- 5.6 vs. 7.9 +/- 2.5, p = .0001) as was the prevalence of H. pylori infection (90.7% in group I vs. 58.1% in group II, p = .001). Hcy levels were elevated (11.7 +/- 5.3 vs. 7.5 +/- 2.7, p = .0001) and folate levels were reduced (13.9 +/- 4.7 vs. 18.6 +/- 4.9, p = .0001) in patients with H. pylori infection, while vitamin B(12) levels were similar in patients with and without H. pylori infection. Correlation analysis revealed a significant negative correlation between plasma folate and Hcy levels and also between folate levels and mean TIMI frame counts (r = -.33, p = .002 vs. r = -.33, p = .003). Moreover, there was a significant positive correlation between plasma Hcy levels and mean TIMI frame counts (r = .66, p = .0001). In addition, the folate level was the only significant determinant of the variance of Hcy in multiple regression analysis (r = -.21, p = .03). Our data showed that plasma folate levels were decreased and plasma Hcy levels were increased in patients with SCF compared to controls. Also, the prevalence of H. pylori infection was increased in patients with SCF. These findings suggest that elevated levels of plasma Hcy, possibly caused by H. pylori infection, and/or a possible disturbance in its metabolism may play a role in the pathogenesis of SCF.

Phosphocalcic Metabolism after Biliopancreatic Diversion

Malabsorptive techniques to treat morbid obesity have been followed by alterations in phosphocalcic metabolism. Knowledge of the preoperative situation is important to assess the influence of these techniques on phosphocalcic metabolism and to consider treatments for these alterations. 61 consecutive morbidly obese patients (50 women, 11 men, age 19 to 63 years) having had biliopancreatic diversion (BPD) were studied in a prospective manner. Preoperative and postoperative levels of calcium, phosphorus, 25-hydroxyvitamin D, tartrate resistant acid phosphate, plasma parathormone (PTH), tubular absorption of phosphate, and urinary calcium and pyridinolines were analyzed, as well as the potential risk factors for their alterations. Follow-up of all patients was a minimum of 4 years. Before BPD, 42.3% of patients presented an increase in PTH and 54% a decrease in the 25-OH vitamin D, but the values of calcium and plasma phosphorus maintained at normal level. 81.8% of the patients with an increase in the PTH maintained high levels after BPD, while 60% of those with a normal preoperative PTH also presented hyperparathyroidism 4 years after the intervention. A correlation between the levels of plasma PTH and body mass index was not found. Morbid obesity is accompanied by a high percentage of hyperparathyroidism. BPD produces malabsorption of vitamin D during the first years, favoring the persistence or appearance of hyperparathyroidism. It is important to recognize and treat the secondary hyperparathyroidism. The postoperative period could necessitate more energetic interventions to get more efficient control of the phosphocalcic metabolism.

Use of isotopes in the diagnosis of hematopoietic disorders

Isotopes of iron have been paramount in clinical tracer studies of hematopoiesis. Kinetics of disappearance from plasma, appearance in circulating erythrocytes, and localization in general areas of bone marrow, spleen, and liver were early revealed by gamma-/beta-emitting Fe-59 with note of characteristic differences of kind and degree of dysfunction among various anemias. Findings have helped in management (e.g., decisions about splenectomy). Positron/gamma-emitting Fe-52 (better for imaging) has provided more detail on marrow expansion and erythropoietic relocation. Other gamma-emitting tracers of hematopoiesis have been In-111 (linked to transferrin) and technetium 99m (Tc-99m) colloids (localizing to reticuloendothelial cells, which have close association with blood cell progenitors), but Fe-52 has proved to be more accurate for recognition of erythropoiesis. Occasional diverse heterotopic sites of hematopoiesis beyond spleen and liver in states of bone marrow disease have posed diagnostic challenges and also raised questions about migration and/or activation of stem cells. Studies of granulopoiesis utilize Tc-99m--labeled leukocytes or Tc99m-labeled antibodies to circulating and progenitor white cells. Iron-deficiency anemias due to malnutrition, malabsorption, blood loss, or special need are explored by dual study (oral vs intravenous) with radioactive (Fe-59, Fe-55) or stable (Fe-54, Fe-57) iron isotopes, which can guide dietary supplementation. Tests for B-12 deficiency in pernicious anemia or malabsorption with radioisotopes of cobalt (Co-57, Co-58) have been upgraded in sensitivity and scope. Rates of oxidation to expired carbon dioxide from particular carbon (radioactive C-14 or stable C-13)--labeled compounds can test B-12 or folic acid deficiencies or gastric infestation as causes of megaloblastic anemias.