METABOLIC EFFECTS OF PARTIAL GASTRECTOMY WITH SPECIAL REFERENCE TO CALCIUM AND FOLIC ACID. II. THE CONTRIBUTION OF FOLIC ACID DEFICIENCY TO THE ANAEMIA

A Case of Severe Hypocalcemia Caused by Malabsorption Due to Partial Gastrectomy and Small Bowel Resection

OBJECTIVE

Calcium is an essential mineral involved in the functioning of nearly every human cell. Calcium levels are regulated by dietary absorption, vitamin D status, and parathyroid hormone (PTH). This report describes a patient in whom childhood bowel resection and partial gastrectomy resulted in malabsorptive hypocalcemia in adulthood.

CASE REPORT

A 21-year-old man presented with syncope and a fall resulting in a right femoral neck fracture. His medical history included small bowel obstructions at age 9 requiring bowel resection, and at age 12 with gastric perforation and partial gastrectomy. Laboratory values showed calcium level of 4.9 mg/dL (8.9-10.3 mg/dL). PTH level was 273 pg/mL (12.0-88.0 pg/mL), 25-hydroxy-vitamin D was 28 ng/dL (30-100 ng/mL), and 1,25-dihydroxy-vitamin D was 54 pg/dL (18-72 pg/mL). Furthermore, magnesium and phosphorus levels were 2.1 mg/dL (1.5-2.6 mg/dL) and 4.4 mg/dL (2.4-4.7 mg/dL), respectively. Calcium levels improved to 9.5 mg/dL on 10% calcium gluconate drip but could not be maintained above 7 mg/dL on oral calcium carbonate supplementation, despite doses as high as 3750 mg three times daily with calcitriol 0.75 mcg twice daily. After switching from calcium carbonate to calcium citrate 3500 mg three times daily, the calcium level improved and was maintained between 8.3 and 9.0 mg/dL.

DISCUSSION

High calcium needs, other nutrient deficiencies, and response to calcium citrate versus calcium carbonate suggest malabsorption from achlorhydria and small bowel resection.

CONCLUSION

This case emphasizes the gastrointestinal physiology in calcium homeostasis and highlights the recognition of hypocalcemia as a complication of gastric and bowel resection.

Long-term effects after partial gastrectomy in elderly men. A longitudinal population study of men between 70 and 75 years of age

Subjects who have had a partial gastrectomy are today mainly found among the elderly. In the population study of 70-year-olds in Gothenburg in 1971-72, 449 men were investigated. Out of these, 10% had had a partial gastrectomy. A total of 331 subjects was re-examined 5 years later at the age of 75. Two groups were recognized in accordance with operative method: Billroth type I (B I) and Billroth type II (B II). In comparison with the non-operated group, the B-II-operated group showed a mean lower body weight of about 6 kg at 70 and 11 kg at 75 years. Although the body weight was lower among operated subjects, no difference was found in the intake of energy and nutrients. There was a greater occurrence of bone fractures among the operated subjects. Tobacco smoking was commoner among subjects with partial gastrectomy. Among the B I and B II groups there was a change in the blood constituents B-hemoglobin, P-vitamin B12, S-calcium, S-ALP, and S-TIBC. At the age of 75 the bone mineral content of the heel bone, as measured with photon absorptiometry, was lower among operated subjects. An increased occurrence of smoking-related cancer was found among subjects with partial gastrectomy.

An audit of the care of post-gastrectomy patients

The records of 26 patients in one practice who had had a partial gastrectomy were studied to see if a stated policy of follow-up had been successful. The policy aimed to detect by annual blood tests (birthday follow-up) the consequences of malabsorption of iron, folate, vitamin B12, and calcium. Of 198 possible tests (nine for each patient when seen for the first screening), only 87 (44 per cent) were done; 16 (18.2 per cent) were abnormal. At the 39 opportunities for annual follow-up, 71 per cent of the possible tests were done; 11 of the 62 tests (17.5 per cent) were abnormal. The most common abnormality was deficiency of iron (12 tests), followed by folate (four tests), serum B12 (two tests), and serum calcium (two tests). Appropriate action according to the review criteria was taken for 24 out of the 27 abnormalities found. The result of the review was to suggest a modified annual follow-up, with fewer than nine tests per year.

Iron overload despite partial gastrectomy

Iron overload was found in 3 patients who had undergone partial gastrectomy: a 61-year-old woman developed iron overload because she may have had idiopathic haemochromatosis and had also been given parenteral iron; in a 62-year-old man with thalassaemia minor, iron overload may have developed because of increased oral iron ingestion, low serum folate, increased, albeit ineffective, erythropoiesis and sideroblastic anaemia; a 74-year-old man with thalassaemia minor developed iron overload without exogenous therapy and died from a hepatoma. These cases illustrate that partial gastrectomy fails to protect patients from developing iron overload, particularly if given uncontrolled iron therapy.

Relative importance of formiminoglutamic and urocanic acid excretion after a histidine load

A thin-layer chromatographic method for the simultaneous assessment of formimino-glutamic (Figlu) and urocanic acid excretion after loading with 15 g. histidine has been applied to 15 control subjects and to 49 selected patients. Upper limits of normal excretion were determined for urocanic acid and Figlu alone (15 mg. and 30 mg/8 hr. respectively), and for the combined metabolites (40 mg./8 hr.). Of the 49 patients studied, 27 excreted total metabolites above 40 mg./8 hr.; of these 19 would have been revealed by their abnormal excretion of Figlu and 22 by their abnormal excretion of urocanic acid. Of 74 tests in the 64 subjects, urocanic acid was present in all but 27% of the tests, and in 29.8% of the tests urocanic acid was in excess of the amount of Figlu excreted. In six normal and six abnormal tests urocanic acid was the sole metabolite present. These results re-emphasize the value of estimating both histidine metabolites in tests for folate deficiency in man, and underline the greater relative importance of urocanic acid.