A CASE OF CHRONIC EXOCRINE PANCREATIC INSUFFICIENCY IN A GASTRIC BYPASS PATIENT chunusabita@gmail.com

 

A CASE OF CHRONIC EXOCRINE PANCREATIC INSUFFICIENCY IN A GASTRIC BYPASS PATIENT

3

Nepal

Oral only

Exocrine pancreatic insufficiency (EPI) is a common complication following Roux-en- Y gastric bypass (RYGB) surgery. Diagnosis can be confirmed via a positive fecal elastase-1 test or noticeable improvement following pancreatic enzyme replacement therapy [1]. Fecal elastase is a highly accurate diagnostic test for EPI [2]. Post-operative diarrhea is a common issue after this type of surgery, with potential causes including dumping syndrome, short bowel syndrome, small intestinal bacterial overgrowth (SIBO), malabsorption of bile acids or carbohydrates, and EPI. EPI, which can result from RYGB due to irregular secretion of pancreatic enzymes, features additional symptoms such as fat maldigestion and steatorrhea. These occur due to procedure-related changes [3]. Therefore, EPI should always be considered as a potential cause of post-operative diarrhea following RYGB surgery.

It’s a case report. A 47-year-old female patient who previously underwent RYGB surgery for morbid obesity 4 years prior presented with complaints of loose stool, fatigue, headache, and nausea that had persisted for 2 weeks. She had not been regularly followed up on an outpatient basis since her surgery. Daily, she experienced six to eight episodes of greasy diarrhea, which worsened after consuming fatty meals. The patient denied any unintentional weight loss or instances of melena. She reported fatigue and progressive weakness, becoming tired even with minimal activity. Her appetite had significantly declined since the onset of these symptoms, and nausea limited her ability to eat and drink.

Adults with a body mass index (BMI) of 35 kg/m2 or higher are suggested to undergo bariatric surgery, whether they have obesity-related comorbidities or not. This procedure is also recommended for diabetic patients with a BMI of at least 30 kg/m2. Bariatric surgery’s benefits on weight loss, comorbidity improvement, cancer risk reduction, and long-term mortality are well-documented [4]. However, this surgery can cause complications like postprandial hypoglycemia, abdominal pain, anastomotic stenosis, deficiencies of iron, vitamins B12, folic acid and D, calcium deficiency, loss of bone density, and kidney stones [5]. Moreover, EPI is a common complication occurring in up to 41.6% of patients after such a procedure and is more prevalent in RYGB compared to sleeve gastrectomy [1]. In the given case, a patient who underwent RYGB 4 years ago due to morbid obesity (BMI ≥40 kg/m2) started showing signs of potential EPI, like diarrhea and steatorrhea, for 2 weeks. This prolonged diarrhea led to an AKI and normal anion gap metabolic acidosis. Iron deficiency and vitamin D deficiency can occur in up to 49% of patients who have undergone RYGB [6,7]. Our patient, who stopped taking her nutritional supplements, also showed deficiencies in iron and vitamin D levels.

EPI is a key complication of RYGB surgery. This condition may cause symptoms such as diarrhea and steatorrhea. If post-operative patients experience diarrhea, a high suspicion of this condition is necessary. Fecal elastase, an affordable and reliable diagnostic test, is used to confirm EPI. Based on the clinical symptoms and/or low fecal elastase levels, pancreatic enzyme replacement therapy can be initiated to alleviate symptoms.