“Bariatric Beriberi”: A Rare Case of Wernicke Encephalopathy Two Weeks After Laparoscopic Sleeve Gastrectomy

Abstract

Wernicke encephalopathy (WE) is an acute neurological syndrome caused by thiamine (vitamin B1) deficiency. This disorder manifests as a triad of gait ataxia, confusion, and vision abnormalities. The absence of a full triad does not rule out WE. Because of its vague presentation, WE is commonly missed in patients with no history of alcohol abuse. Other risk factors for WE include bariatric surgery, hemodialysis, hyperemesis gravidarum, and malabsorption syndromes. WE is a clinical diagnosis that can be confirmed with an MRI of the brain as hyperintensities in the mammillary bodies, periaqueductal area, thalami, and hippocampus. If suspected in a patient, WE must be immediately treated with intravenous thiamine to prevent evolution into Korsakoff syndrome, coma, or death. Currently, there is no consensus in the medical community as to how much thiamine must be given and for how long. Therefore, there is a need for more research in the diagnosis and management of WE after bariatric surgery. Herein, we report a rare case of a 23-year-old female with a history of morbid obesity who developed WE two weeks after a laparoscopic sleeve gastrectomy.

Case report: Wernicke–Korsakoff syndrome after bariatric surgery

“…Although this condition is likely underdiagnosed, Chang et al stated that WE occurs in less than 1% of all patients after receiving BS (15). According to Bathobakae et al, only approximately 15% of all WE cases are diagnosed antemortem due to the ambiguous set of neurological symptoms (9). Olmsted et al, in autopsy studies, revealed that up to 80% of cases of WKS are not diagnosed using the criteria of classical symptoms and signs, such as mental confusion, ocular signs, and ataxia.…”

“…However, the clinical findings and the effectiveness of the treatment appeared to be sufficient for the diagnosis of WKS. Radiological examination by magnetic resonance imaging (MRI) can be used to confirm the diagnosis of WE (9). A positive test is characterized by hyperintensities in the periventricular areas of the mammillary bodies, thalamus, and periaqueductal and periventricular regions (9,11).…”

“…Radiological examination by magnetic resonance imaging (MRI) can be used to confirm the diagnosis of WE (9). A positive test is characterized by hyperintensities in the periventricular areas of the mammillary bodies, thalamus, and periaqueductal and periventricular regions (9,11). This diagnostic tool has a sensitivity of 50-53% (3, 9, 11) and a specificity of 93% in WE diagnosis (9,11).…”

“…This syndrome is composed of two distinct phases: first, Wernicke Encephalopathy (WE) an acute phase characterized by a clinical triad of mental confusion, ophthalmoplegia, and ataxia (8). The full triad has been reported in less than 30% of cases, and its absence does not exclude the possibility of WE (9). The acute phase is followed by the chronic phase of WKS, known as Korsakoff 's syndrome (KS) and characterized by the presence of anterograde amnesia and confabulation (8).…”

Nutritional management during critical illness in those with previous obesity surgery

“…Micronutrient supplementation is often necessary, according to laboratory results. However, due to the unavailability of some vitamin dosages and uncertainty of the added clinical value of such dosages in many regions of the world, empirical supplementation is commonly recommended immediately, given the potential of vitamin deficiencies as a cause of hospital admission, such as thiamine deficiency for those in the late postoperative phase [24 ▪ ].…”