SESSION TITLE: Pulmonary Vascular Disease Student/Resident Case Report Posters I
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Micronutrient deficiencies are a well known complication of gastric bypass surgery, with one such micronutrient being vitamin B12. As this vitamin's defeciency is associated with increased serum levels of homocystine, we are reporting a case of a patient who suffered multiple venous thromboses, including pulmonary emboli, in the setting of vitamin B12 defeciency secondary to gastric bypass surgery.
CASE PRESENTATION: Our patient is a 54 years old lady who had morbid obesity managed with gastric bypass surgery in 1977. She presented to our emergency room complaining of nausea and anorexia for the preceeding 10 days associated with 10 lbs weight loss. In addition, she had exertional dyspnea, projectile vomiting and diarrhea. An EKG did not show any acute changes, and cardiac enzymes were within normal limits, ruling out myocardial ischemia. CT with contrast of the abdomen revealed superior mesenteric vein thrombosis along with portal vein thrombosis. CT angiography of the chest was also obtained, which showed multple bilateral pulmonary emboli. However, Doppler ultrasound of upper and lower extremities did not demonstrate any evidence of thromboses. In light of the emboli found, heparin infusion was started with a UFH target of 0.7. On the third day of admission, warfarin was initiated. Hypercoaguable workup showed factor II level to be slightly elevated, and the prothrombin 20210A mutation was negative. Her homocysteine level was found to be 96 "normal range 4-10 μmol/L" and she was a compound hetereozygote for MTHFR mutation. Vitamin B12 was 102 pg/ml and folic acid was 2.7 ng/ml. Oral replacement was initiated. The patient has done clinically well in outpatient follow up.
DISCUSSION: Weight-reduction surgeries are an effective and widely accepted measure of rapid weight loss. As the population undergoing such surgeries is increasing, the side effects are becoming more easily identifiable. Vitamin defeciencies being a known side effect and preventable with oral supplements may have an underestimated impact. The patient's compliance and education are mandatory in such circumstances to prevent fatal complications such as multiple venous thromboses and embolization from vitamin B12 defeciency.
CONCLUSIONS: Hyperhomocystenemia is a well known thrombogenic state. Vitamin B12 defeciency is an infrequent but significant cause that has to be prevented in the setting of gastric bypass surgery patients. Physicians have to recognize this risk factor in every gastric bypass surgery patient who develop thromboses or emboli.
Reference #1: Nodular regenerative hyperplasia, portal vein thrombosis, and avascular hip necrosis due to hyperhomocysteinaemia O Buchel, T Roskams, B Van Damme, F Nevens, J Pirenne, J Fevery. Gut 2005;54:1021-1023. doi: 10.1136/gut.2004.055921
Reference #2: Venous thrombosis associated with pernicious anaemia. A report of two cases and review MARTA BARRIOS & CAROL ALLIOT. Hematology, April 2006; 11(2): 135-138
DISCLOSURE: The following authors have nothing to disclose: Aahd Kubbara, Shipeng Yu, Danae Hamouda, Youngsook Yoon
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