Brown Bowel Syndrome Secondary to Jejunoileal Bypass: The First Case Report

Abstract

A 58-year-old woman with a surgical history of jejunoileal bypass in 1980 for weight reduction sought medical attention with multiple complaints. The patient had not been taking any nutritional supplements since her bypass surgery, 26 years previously. She was found to have osteomalacia, chronic diarrhea, secondary hyperparathyroidism, and hyperoxaluria with a frequent history of nephrolithiasis. Because of her severe osteodystrophy and metabolic complications, reversal of her jejunoileal bypass was recommended. Reversal of the jejunoileal bypass with a sleeve gastrectomy was performed. Laparotomy revealed brown discoloration of the entire alimentary limb with atrophy of the bypassed intestinal limb. Histologic examination of the resected small bowel demonstrated brown pigment deposits within smooth muscle cells of the bowel wall. The pigment stained positive with Fontana-Masson most likely representing lipofuscin. We report a case of brown bowel syndrome complicating jejunoileal bypass, the first case reported in the literature to the best of our knowledge.

Brown Bowel Syndrome: A Rare Complication in Diseases Associated with Long-Standing Malabsorption

“…Indeed, brown bowel syndrome was recently reported in a patient in whom a jejunoileal bypass had been created 26 years previously [2]. So even a ‘jejunoileal bypass' as an unusual old procedure may be associated with brown bowel syndrome [2].…”

“…Indeed, brown bowel syndrome was recently reported in a patient in whom a jejunoileal bypass had been created 26 years previously [2]. So even a ‘jejunoileal bypass' as an unusual old procedure may be associated with brown bowel syndrome [2]. Over the course of time the vitamin E deficiency or lipofuscinosis may cause neuronal functional disorders that, as a result, affect bowel motility to a considerable degree [15].…”

“…Following malabsorptive techniques of obesity surgery (in particular biliopancreatic diversion), vitamin E deficiency is common. Screening and appropriate supplementation (not only of vitamin E deficiency, but also of a wide range of other macro- and micronutrients) are therefore a crucial aspect of routine long-term follow-up [2]. …”

“…To determine the levels of the individual tocopherols, high-performance liquid chromatography, gas chromatography, and the combined techniques high-performance liquid chromatography-mass spectrometry and gas chromatography-mass spectrometry are employed [33,34]. Further studies in this area would be desirable to more precisely distinguish the actual vitamin E deficiency in the various conditions by measuring serum levels in patients with malabsorptive disorders (celiac disease, chronic pancreatitis, and chronic inflammatory bowel diseases), motility disorders (recurrent pseudo-obstruction, myopathy), and in patients with chronic atresia or atonia and after bariatric surgery [2,7]. …”

“…In particular, a deficit in fat-soluble vitamins such as vitamin A, D, E, and K is associated with symptoms of dry skin, concentration disorders, fatigue, poor wound healing, coagulatory disorders, increased susceptibility to infection, and other cognitive and neurological deficits [1]. The main function of vitamin E (tocopherol) as an antioxidant membrane lipid is to guard against auto-oxidation or pathological oxidation induced by free radicals; thus, a deficiency in this vitamin causes damage to the phospholipid layer of the mitochondrial membrane via free radicals with the resulting development of lipofuscin deposits [2]. Such a deficiency is also associated with an increase in lipofuscinosis of the bowel, i.e.…”