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Cardiomyopathy

Selenium deficiency linked to cardiac problems post-bypass

Nuts are an important source of selenium, which may prevent cardiomyopathy post-bypass. Photo: Flickr / steffenz
Case study reported selenium deficiency as a reversible cause of unexplained cardiomyopathy in patients with gastric bypass
Second case report highlights the crucial role primary care physicians have managing and following bariatric patients

Non-compliance with vitamin and mineral supplementation protocols after bariatric surgery could lead to nutritional deficiencies and related health complications, according to two separate case reports presented at the American College of Gastroenterology's (ACG) 77th Annual Scientific meeting in Las Vegas.

In the first case report, Dr Mustafa Huseini and colleagues from the Geisinger Medical Center, reported that although rare in developed countries, selenium deficiency may occur in individuals with chronic malabsorptive states such as patients with history of gastric bypass, and long term selenium-deficient parenteral nutrition.

"Selenium is an essential trace element that plays an integral role in normal myocardial function so supplementation may be beneficial for individuals who are at risk of low absorption, such as gastric bypass patients," said Huseini. He described the case of a 39 year female who underwent gastric bypass seven years before presenting to the emergency department for evaluation of change in mental status, generalised weakness and several days of poor oral intake.

On initial evaluation patient was noted to be hypotensive and in mild respiratory distress. After two days of hospital admission, she developed respiratory and circulatory collapse requiring endotracheal intubation and mechanical ventilation. A 2D echocardiogram showed a left ventricular ejection fraction of less than 20%.

A cardiac catheterisation revealed non-obstructive coronary artery disease. Nutritional evaluation revealed decreased levels of selenium (29 mcg/L; normal values: 63-160mcg/L).

"After adequate supplementation with selenium, cardiac function improved and a repeat 2D echocardiogram demonstrated normalised ejection fraction of 55%," said Huseini. "This case emphasises the role of considering selenium deficiency as a reversible cause of unexplained cardiomyopathy in patients with gastric bypass besides otherwise impaired nutritional status."

The second case report from researchers at the University of Missouri concerned a non-compliant patient who failed to maintain regular follow-up after undergoing bariatric surgery, leading to severe vitamin and mineral deficiencies.

The 38-year old female patient underwent Roux-en-Y gastric bypass surgery but had limited follow-up during the five years since her surgery, when she presented with several weeks of fatigue. She lost nearly 104lbs (47kgs) since her surgery and was poorly compliant with her vitamin and mineral supplements, according to co-investigator Dr Hazem Hammad.

"When she came in for medical care she was pale and had a slight soft ejection systolic murmur," said Hammad, who noted that she had hemoglobin of 4.7g/dL and marked mineral and vitamin deficiencies, including low levels of Vitamin B12, Vitamin D, Zinc, and Iron.

After receiving counselling about the crucial benefits of long term follow-up and compliance with vitamin supplements, the patient was discharged to complete an intravenous iron supplementation treatment course and to follow up with a bariatric surgery multidisciplinary centre.

Two weeks following discharge she received additional counselling from her primary care physician and was given a handout that outlined vitamin supplementation following bariatric surgery along with written information that included how to obtain bariatric vitamins via website, phone and from pharmacies. Three months following discharge laboratory tests revealed an increase in haemoglobin to 10.8g/dL and an improvement in her vitamins and mineral deficiency status.

"The pre- and post-operative management of bariatric surgery patients is clearly multidisciplinary. United States guidelines define the primary team as comprising the bariatric surgeon, the obesity specialist and the dietician," said Hammad. "Primary care physicians, however, have a significant role in managing and following these patients by providing crucial patient education and support as illustrated in our case."

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