This article appeared within the July/August 2021 subject of Discover journal as “Slim to None.” Subscribe for extra tales like these.
Ann was a long-standing affected person of mine whom I noticed for extreme gastroesophageal reflux illness, also referred to as GERD. She was extraordinarily obese and met medical standards for morbid weight problems. Doctors think about a affected person morbidly overweight when they’re no less than 100 kilos over their excellent physique weight — and/or when their weight could considerably contribute to medical situations, like diabetes, hypertension, or fatty liver illness, that put their life in peril. Ann was 5 toes 4 inches tall and weighed 250 kilos. She had been a slim 130-pound athlete as a teen, however had gained weight with every of her pregnancies.
During one in all our clinic visits, the subject of her presumably present process surgical procedure to drop extra pounds got here up. I used to be supportive of Ann seeing a surgeon who specialised on this space. Such procedures, often called bariatric surgical procedures, have turn out to be extraordinarily standard with sufferers, given their excessive success charges and the usually dramatic and life-changing outcomes that they’ll produce.
Several bariatric surgical procedures exist, however after assembly with our surgeon, Ann had determined to bear a selected bariatric process often called a Roux-en-Y gastric bypass. This specific operation usually leads to probably the most dramatic and sturdy weight reduction for sufferers. The surgical procedure entails the creation of a small “pouch” constructed from a portion of the abdomen. This pouch can solely maintain a small quantity of meals at a given time and is related to a bit of small gut. The remaining portion of the abdomen, which is related to the highest of the small bowel, is solely left in place.
But after the process, ingested meals now not flows by way of these areas of the gastrointestinal tract; that is the “bypass” that’s referred to within the operation’s title. Food that’s swallowed bypasses the start of the small gut and enters the bowel, the place it’s digested a lot additional down the road. After this surgical procedure, sufferers drop extra pounds by a number of means. For one, the surgical procedure restricts how a lot they’ll eat at a given time as a result of the pouch is so small in comparison with a traditional abdomen. Beyond that, a lot of the small bowel, the place meals is often absorbed, by no means sees ingested meals anymore. As a bonus, the Roux-en-Y gastric bypass can also be very efficient at treating GERD. Ann underwent the surgical procedure with none issues.
The first 12 months after the surgical procedure was a really thrilling time for Ann. She misplaced virtually 75 kilos, her self-image soared, and she or he handled herself to a completely new wardrobe. Victory, it appeared, was at hand.
I used to be due to this fact understandably stunned to see Ann again in my clinic simply three months after her one-year surgical anniversary. Looking troubled, she advised me that she felt weak and drained on a regular basis. She had seen a plethora of recent issues, together with imaginative and prescient adjustments and straightforward bruising, with even minor bumps leading to ugly crimson blotches on her legs and arms. Most regarding, Ann’s weight reduction was persevering with past the purpose that might be anticipated following a gastric bypass. She had now misplaced over 100 kilos and had gone from trying sturdy to, fairly frankly, sickly. Most sufferers expertise a weight-loss plateau at across the one-year mark, however Ann’s weight had continued to say no.
Ann was severely anxious she had developed a cancerous tumor that might clarify her weight reduction — a not-unreasonable concern. But a CT scan of her stomach and pelvis didn’t disclose any apparent abnormalities. I additionally carried out an higher endoscopy and a colonoscopy on Ann to ensure nothing was amiss along with her gastric bypass and to additional make sure that she didn’t have colon most cancers; the procedures did not reveal something which may clarify her weight reduction. But blood exams that I carried out confirmed that Ann was affected by vital malnutrition. In addition, her straightforward bruising prompted me to test her vitamin ranges, since vitamin Okay deficiency is incessantly related to bruising. Her vitamin Okay stage was extraordinarily low, as was her vitamin A stage.
Now we additionally had a solution for her imaginative and prescient adjustments, as vitamin A is required for wholesome imaginative and prescient. Both vitamin Okay and A are among the many so-called “fatsoluble” nutritional vitamins, that means that they don’t dissolve in water, however in fats. Vitamin A and Okay deficiencies are uncommon, and Ann was taking a multivitamin that included each of those. This advised that Ann’s consumption of the nutritional vitamins themselves was enough, however her physique merely wasn’t absorbing sufficient of the vitamins they contained.
When I requested Ann if she was having diarrhea, she stated she was having as much as 4 bowel actions per day. I requested her if her stools appeared oily or greasy. Her eyes widened and she or he nodded. “I haven’t advised anybody that but,” she stated. The medical time period for greasy stools is steatorrhea, and the presence of fats in stool is regarding. The human physique is extraordinarily environment friendly at absorbing fats from meals, doubtless reflecting earlier eras when fats was a uncommon dietary commodity. Fat within the stool, nonetheless, is a telltale signal that the physique is unable to soak up ingested meals correctly. Fat-soluble nutritional vitamins are absorbed passively by the physique together with ingested fats, however for those who can’t take in fats, you’ll be able to’t take in fat-soluble nutritional vitamins, and deficiencies will develop.
While most individuals suppose their abdomen digests their meals, it’s really the pancreas that does a lot of the work. The pancreas produces enzymes that break down carbohydrates, fat, and proteins into their fundamental constructing blocks, which the small gut can then take in. Steatorrhea is mostly seen in sufferers with persistent pancreatitis. That situation often develops on account of alcohol abuse, genetic elements, or different causes. In these sufferers, the pancreas turns into scarred and atrophic and may now not make or launch sufficient pancreatic enzymes.
The pancreas is often chargeable for digesting meals.(Credit: Kellie Jaeger/Discover)
But Ann didn’t have persistent pancreatitis — her CT scan had proven a traditional pancreas. Still, I started to marvel if Ann was affected by asynchrony. Asynchrony can generally develop after complicated bowel reconstructions, together with a Rouxen-Y gastric bypass. In order for regular digestion to happen, all elements of the intestine not solely should work the best approach, but additionally on the proper time and in the best place, like a finely choreographed ballet. Ann’s gastric bypass meant that her meals was happening one limb of small bowel, however her pancreas was dumping digestive enzymes into one other, and there was no meals going by way of that space in any respect. As a end result, the meals was not interacting with the enzymes that had been required to interrupt it down. Her physique was merely passing undigested meals by way of her.
I gave Ann a prescription for pancreatic enzymes— drugs containing digestive enzymes obtained from pigs, consider it or not. When taken with a meal, these enzymes activate and break down meals identical to enzymes from a human pancreas. Then, the small gut can take in these smaller molecules. Within a number of days of beginning the remedy, Ann’s stools had normalized and her weight reduction stopped. A blood take a look at obtained a number of weeks later confirmed that her vitamin ranges had been on the rise.
Ann would want to take supplemental enzymes for the remainder of her life, so her physique might preserve a fascinating weight and her absorption of meals could be regular. She was not joyful in regards to the further drugs, however they labored. The gastric bypass giveth, and the gastric bypass taketh away.
Douglas G. Adler is co-director of the Center for Advanced Therapeutic Endoscopy in Denver. The circumstances described in Vital Signs are actual, however names and sure particulars have been modified.