Secondary Kwashiorkor Disease in a Patient with Gastric Bypass Surgery and Short Gut Syndrome

Abstract

Patient: Female, 60-year-old Final Diagnosis: Malnutrition Symptoms: Edema Medication:— Clinical Procedure: — Specialty: General and Internal Medicine Objective: Rare disease Background: Kwashiorkor disease is a subtype of severe acute protein malnutrition characterized by peripheral edema associated with hypoalbuminemia and ascites. It can result from both protein deficiency and protein loss. In resource-poor countries, the disease often is caused by inadequate dietary intake, but in resource-rich countries, it can be seen as a rare complication of severe malabsorption. Case Report: We present the case of a 60-year-old woman who presented with 1 week of progressive anasarca in the setting of decreased dietary intake and poor tolerance of total parenteral nutrition (TPN). She had a history of Roux-en-Y gastric bypass surgery which was complicated by a strangulated internal hernia that required an exploratory laparotomy and small bowel resection. She subsequently developed short gut syndrome with TPN dependence. Work-up revealed hypoalbuminemia with several micronutrient deficiencies consistent with secondary kwashiorkor disease. With a multidisciplinary approach that included Gastroenterology, Pharmacy, and Nutrition, she was treated with albumin, furosemide, nutritional supplementation, and ultimately rechallenged with TPN. At discharge, her swelling had improved, her weight had decreased, and her albumin improved to the normal range. Conclusions: This case is a unique presentation of secondary kwashiorkor disease. In our patient, the combination of gastric bypass surgery and short gut syndrome with poor TPN tolerance likely led to severe protein malabsorption. This underscores the importance of recognizing the signs and symptoms of kwashiorkor disease and understanding the associated complications so that treatment can be instituted promptly. Furthermore, the case demonstrates how an interdisciplinary approach to management can increase the chance of a successful outcome.

Subclinical Kwashiorkor in Adults

“…[ 46 ] However, adult kwashiorkor has also been described in the literature. [ 17 18 19 ] Kwashiorkor has been reported post bariatric surgery and/or short-gut syndrome. [ 17 19 ] Zhu (2019) reported kwashiorkor in a 60-year-old alcohol-dependent male.…”

“…[ 8 9 10 11 12 13 ] Childhood protein-energy undernutrition (PEU) or protein-energy malnutrition (PEM) is a widely discussed and accepted global problem. [ 8 9 10 11 12 13 14 15 16 ] However, though PEU is reported in adults,[ 17 18 19 ] it continues to be an under-recognized entity that does not receive the attention it should. [ 20 ]…”