D0666 - Hypocupremia Presenting 14 Years After Roux-en-Y Gastric Bypass

Michael Wagner, DO, Bushra Zia, MBBS, Nicolas Cal, DO
Baystate Medical Center, Springfield, MA

Introduction: Copper deficiency is a well-established, but under recognized sequela of bariatric surgery. We present a case of acquired copper deficiency in a patient, 14 years after Roux-en-Y gastric bypass.

Case Description/Methods: A 39-year-old female with history of Roux-en-Y gastric bypass (RYGB) 14 years ago and cholecystectomy 3 years ago, was referred to the gastroenterology clinic for epigastric pain with nausea, vomiting and diarrhea ongoing for a few months. Her review of systems was also positive for fatigue, lack of energy and bilateral hand numbness. Initial work up showed a white blood cell count of 2.5k/m3 with low neutrophil count of 28%, macrocytosis with MCV of 103.8 fL, cobalamin of 239 pg/ml, folate of 12.7 ng/ml, low copper of 8 µg/dL, and elevated zinc of 126µg/dL. She was started on copper supplementation. A bidirectional endoscopy to evaluate for abdominal pain and diarrhea was also performed that showed a small anastomotic ulcer but was otherwise normal. Within 4 weeks of copper supplementation, her copper level improved to 92µg/dL. The patient also reported resolution of weakness and hand numbness. Her leukopenia, neutropenia and macrocytosis also normalized as shown in table. Her diarrhea resolved with cholestyramine.

Discussion: Micronutrient deficiencies are a well-known complication of bariatric surgery. These occur due to a combination of decreased intake as well as poor absorption. Acquired copper deficiency can be seen in 10-20% of patients after RYGB and can lead to hematological and neurological sequelae if not diagnosed and managed in a timely manner. American Society for Metabolic & Bariatric Surgery recommend copper supplementation for all post RYGB patients with 2 mg/day along with annual screening for copper deficiency even in the absence of symptoms. Our patient also had zinc overload, which is an additional risk factor for copper deficiency. Zinc competes with copper for absorption, and therefore can lead to decreased intestinal uptake. Despite being a well-recognized mineral deficiency post bariatric surgery, copper deficiency remains underdiagnosed as it has a variable clinical presentation and is often confounded by other micronutrient deficiencies, especially cobalamin. While the hematological abnormalities resolve within 4-8 weeks of repletion, the neurological recovery is variable and can sometimes be irreversible, making prompt recognition and management of copper deficiency essential.



Disclosures:


Michael Wagner, DO, Bushra Zia, MBBS, Nicolas Cal, DO. D0666 - Hypocupremia Presenting 14 Years After Roux-en-Y Gastric Bypass, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.