University of Hawaii School of Medicine Honolulu, HI, United States
Eric Wien, MD1, Scott Kuwada, MD2 1University of Hawaii School of Medicine, Honolulu, HI; 2The Queen's Medical Center GI Services and Liver Center, Honolulu, HI
Introduction: Severe thiamine (Vitamin B1) deficiency can present as Wernicke-Korsakoff Syndrome, wet beri beri, or dry beri beri. Though an uncommon cause of neuropathy, if left untreated it often results in death. We present the case of a 47-year-old non-alcoholic male who was found to have dry beri beri five years after a gastrojejunostomy performed for small bowel obstruction.
Case Description/Methods: A 47-year-old male with Protein C deficiency on warfarin, severe protein calorie malnutrition, and prior gastrojejunostomy for SBO 5 years prior to admission, presented with altered mentation after a fall in his bedroom. Labs were unremarkable except for Hgb 8.8 g/dL, MCV 89.2 fL and INR 4.1. CT head showed acute on chronic left subdural hematoma with 1.9cm right midline shift. IV Vitamin K and Kcentra were administered and a left burr hole evacuation was performed. On hospital day 5, the gastroenterology service was consulted for weight loss and severe malnutrition. The patient denied any chronic diarrhea, abdominal pain, nausea, vomiting, melena, or hematochezia. Physical exam was notable for a nontender abdomen with a large well-healed midline abdominal surgical scar and a large midline hernia. The patient was alert, but with retrograde amnesia and glove and stocking paresthesia. CT abdomen and pelvis revealed prior gastrojejunostomy. Endoscopy demonstrated gastrojejunostomy with patchy mildly scalloped duodenal mucosa, and patchy erythema of the gastric mucosa. Biopsies were normal. Whole blood thiamine was 18 nmol/L (N= 78-185nmol/L) and the patient was treated with IV thiamine for dry beri beri with improvement of his neurologic symptoms.
Discussion: Thiamine deficiency is a rare cause of neuropathy most commonly associated with alcohol use. Though rare, it has been described following gastrectomy and gastrojejunostomy likely due to the majority of absorption occurring in the duodenum. Inadequate intake, severe and unremitting vomiting, decreased conversion of thiamine to the active coenzyme, reduced hepatic storage in the presence of alcohol related fatty liver, direct ethanol inhibition of small bowel thiamine transport (absorption), and altered absorption related to other nutritional deficiencies are potential causes. Typically presenting with progressive symmetric extremity weakness, it can mimic Guillain-Barré Syndrome. Patients demonstrate rapid improvement after thiamine supplementation. Thiamine deficiency should be considered in patients with neurologic symptoms following gastrojejunostomy.
Eric Wien indicated no relevant financial relationships.
Scott Kuwada indicated no relevant financial relationships.
Eric Wien, MD1, Scott Kuwada, MD2. P2061 - Symptomatic Vitamin B1 Deficiency After Gastrojejunostomy, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.