Wernicke encephalopathy after bariatric surgery: Losing more than just weight

Abstract

Wernicke encephalopathy after bariatric surgery: Losing more than just weight D. Foster, DO; M. Falah, MD; N. Kadom, MD; and R. Mandler, MD Bariatric surgery is a frequent treatment for obesity. Neurologic complications after surgery include encephalopathy, behavioral abnormalities, seizures, cranial nerve palsies, ataxia, plexopathy, myelopathy, polyneuropathy, mononeuropathy (carpal tunnel syndrome, meralgia paresthetica), compartment syndrome, neuropathy, and myopathy. In particular, Wernicke encephalopathy, caused by vitamin B1 deficiency, can result in permanent neurologic deficit. 1,2 We report unusual clinical and imaging findings in a postgastric bypass patient with Wernicke encephalopathy.Case report. A 35-year-old woman underwent gastric bypass surgery for obesity. Subsequently, she reported anorexia, nausea, vomiting, and generalized fatigue, resulting in hospitalization. The patient continued to develop progressive hearing loss, psychomotor slowing, apathy, forgetfulness, ataxia, and bilateral hand paresthesias. In the 12th postoperative week, she had lost 40 lbs, was lethargic and confused, and had difficulty walking. She was awake but not attentive, speech was fluent, and comprehension was decreased. Pupils were equal and reactive to light, extraocular movements were intact, there was no nystagmus, and hearing was diminished. Strength was 3/5 in the lower extremities and normal in upper extremities, vibratory sense was diminished in feet, deep tendon reflexes were absent, plantar reflexes were down-going, and gait was wide-based. Laboratory tests were normal for blood count, thyroid function, vitamin B 12 , and CSF. Abnormal results included a slight elevation in liver enzymes, high serum glucose (163 mg/dL), and low serum potassium (2.6 MEq/L). EEG and head CT were normal.The patient's mental status continued to decline despite treatment for dehydration. Upon admission to our hospital, the heart rate was 125 beats/min; she opened her eyes to nail bed pressure but followed no commands and was nonverbal. The pupils were round and fixed at 3 mm, oculocephalic and deep tendon reflexes were absent, plantar reflexes were down-going, and general muscle tone was flaccid without spontaneous movements or withdrawal to painful stimuli. Abnormal test results were as follows: serum glucose (256 mg/dL), CSF protein (90 mg/dL), and diffuse slowing on EEG. Pretreatment red blood cell transketolase and serum thiamine levels were not down. The first MRI showed bilateral symmetric hyperintense signal on T2-weighted and fluidattenuated inversion recovery (FLAIR) images at the floor of the fourth ventricle, periaqueductal gray matter, the medial portions of both thalami, and the premotor and motor cortices (figure, A through C). All T2 hyperintense regions demonstrated contrast enhancement. Restricted diffusion was seen in the same regions on diffusionweighted imaging (DWI) and apparent diffusion coefficient maps.Initially, thiamine 100 mg IV showed no clinical improvement. Subsequently, high-dose thiamine (100 mg ...

Recommended Nutritional Supplements for Bariatric Surgery Patients

“…Thiamine deficiency appears most likely to occur in patients who experience unexpected persistent vomiting and/or unusually rapid weight loss (>7 kg/mo) after surgery. [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34] Three case reports of patients who had vertical banded gastroplasty describe similar presenting symptoms of weakness, dizziness, and blurred vision occurring 3-5 months after surgery. 19,23 On admission, each patient was notable for persistent vomiting, inadequate food intake after surgery, and postsurgery weight loss of around 30 kg.…”

Wernicke Encephalopathy and Sleeve Gastrectomy: A Case Report and Literature Review

“…Also, WE after bariatric surgery has been associated with atypical features including optic neuropathy, papilledema, deafness, paresis, seizures, myoclonus, and asterixis. 20 Approximately 80 percent of alcohol abusers recovering from classic WE exhibit the selective memory disturbance of KS, which is an amnestic-confabulatory condition characterized by severe anterograde and retrograde amnesia that emerges as ocular manifestations and acute encephalopathy subside. In contrast, KS is a less frequent sequela of WE in nonalcohol abusers.…”

Encefalopatía de Wernicke y polineuropatía asociada a déficit de complejo B después de una cirugía bariátrica

“…Esta tríada es un elemento teórico no muy aplicable, ya que su presentación varía según el estudio, los criterios y la consideración específica, presentándose variablemente entre el 10 % y máximo el 56 % de los pacientes (1,8,14,19,21,22,24,25). Esta variabilidad en su presentación puede llevar a un subdiagnóstico o subregistro importante, que puede ser secundario a las diferentes formas de presentación o a la asociación de esta entidad con enfermedades concomitantes (1,8,14).…”

“…Se recomienda, en pacientes después de cirugía bariátrica con síntomas neurológicos sugestivos de una deficiencia de tiamina (encefalopatía de Wernicke o polineuropatía), iniciar un tratamiento intravenoso agresivo con tiamina (mínimo 100 mg/ día) por 7 a 14 días (1,3,4,6,7,9,19,24,25,27,29).…”