Panazzolo Diogo Guarnieri, Braga Tássia Gomide, Bergamim Anice, Pires Bárbara, Almeida Hirlena, Kraemer-Aguiar Luiz Guilherme
Obesity Unit, Polyclinic Piquet Carneiro; Endocrinology, Department of Internal Medicine, Medical Sciences Faculty, State University of Rio de Janeiro, Av, Marechal Rondon, 381, Rio de Janeiro 20950-003, Brazil.
J Med Case Rep. 2014 Oct 28;8:357. doi: 10.1186/1752-1947-8-357.
In this report, we describe challenges we encountered in the clinical management of a patient with hypoparathyroidism who had previously undergone a bariatric procedure.
We report the case of a 38-year-old Caucasian woman who had undergone a Roux-en-Y gastric bypass procedure for treatment of obesity. She also had a past history of right lobectomy to treat a benign thyroid nodule. Another thyroid nodule was diagnosed after her bariatric surgery, so a new thyroid surgery was performed. Permanent hypoparathyroidism occurred after the second thyroid surgery. A Roux-en-Y gastric bypass resulted in important weight loss, but the preferential site of calcium absorption was bypassed. The lack of endogenous parathyroid hormone secretion due to post-surgical hypoparathyroidism abolished the physiological mechanism that compensates the reduced calcium absorption, which was a challenge for us to overcome. In this report, we describe our clinical therapeutic choices to maintain normocalcemia and normophosphatemia in this patient. Higher doses of exogenous calcium citrate, calcitriol and cholecalciferol were used, but hypocalcemia was still present. To improve vitamin D absorption with resultant improvement of calcium homeostasis, we speculated that adding pancrelipase to meals would increase lipid absorption and possibly fat-soluble vitamins, including vitamin D. Only after the addition of pancrelipase did the patient improve without weight regain according to clinical and laboratory assessments.
The use of exogenous pancreatic enzymes improved calcium homeostasis in this bariatric patient. The role of these enzymes on vitamin D absorption and subsequent rise in calcium levels in hypoparathyroid patients who undergo bariatric procedures need further investigation.
在本报告中，我们描述了在一位曾接受减肥手术的甲状旁腺功能减退患者的临床管理中遇到的挑战。
我们报告了一名38岁的白种女性病例，她曾接受Roux-en-Y胃旁路手术治疗肥胖症。她既往有因治疗良性甲状腺结节而行右叶甲状腺切除术的病史。减肥手术后又诊断出一个新的甲状腺结节，因此进行了一次新的甲状腺手术。第二次甲状腺手术后发生了永久性甲状旁腺功能减退。Roux-en-Y胃旁路手术导致体重显著减轻，但钙吸收的优先部位被绕过。由于手术后甲状旁腺功能减退导致内源性甲状旁腺激素分泌缺乏，消除了补偿钙吸收减少的生理机制，这是我们需要克服的一个挑战。在本报告中，我们描述了为使该患者维持血钙正常和血磷正常而做出的临床治疗选择。使用了更高剂量的外源性柠檬酸钙、骨化三醇和胆钙化醇，但仍存在低钙血症。为了改善维生素D吸收并由此改善钙稳态，我们推测在餐食中添加胰脂肪酶会增加脂质吸收，并可能增加包括维生素D在内的脂溶性维生素的吸收。仅在添加胰脂肪酶后，根据临床和实验室评估，患者病情改善且体重未反弹。
外源性胰酶的使用改善了这位减肥患者的钙稳态。这些酶在接受减肥手术的甲状旁腺功能减退患者中对维生素D吸收及随后钙水平升高的作用需要进一步研究。
