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The spectrum of gluten-related disorders was restricted to coeliac disease and wheat allergy, but the new contemporary entity referred to as noncoeliac gluten sensitivity has gained recognition mainly in adults but also in children. Noncoeliac gluten sensitivity is defined as the presence of a variety of symptoms related to gluten ingestion in patients in whom coeliac disease and wheat allergy have been excluded. The pathophysiology and biomarkers of coeliac disease and wheat allergy are well known, but this is not the case for noncoeliac gluten sensitivity. It is also not clear whether noncoeliac gluten sensitivity is caused by consumption of gluten or by consumption of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. Randomized trials on noncoeliac gluten sensitivity in children are lacking and are hardly needed to evaluate its role in paediatric patients with gastroenterology to avoid the use of unnecessary restrictive diets in children and interference with proper diagnosis of coeliac disease.

Background: Environmental enteric dysfunction (EED) refers to an incompletely defined syndrome of inflammation, reduced absorptive capacity, and reduced barrier function in the small intestine. It is widespread among children and adults in low- and middle-income countries. Understanding of EED and its possible consequences for health is currently limited., Objective: A narrative review of the current understanding of EED: epidemiology, pathogenesis, therapies, and relevance to child health., Methods: Searches for key papers and ongoing trials were conducted using PUBMED 1966-June 2014; ClinicalTrials.gov; the WHO Clinical Trials Registry; the Cochrane Library; hand searches of the references of retrieved literature; discussions with experts; and personal experience from the field., Results: EED is established during infancy and is associated with poor sanitation, certain gut infections, and micronutrient deficiencies. Helicobacter pylori infection, small intestinal bacterial overgrowth (SIBO), abnormal gut microbiota, undernutrition, and toxins may all play a role. EED is usually asymptomatic, but it is important due to its association with stunting. Diagnosis is frequently by the dual sugar absorption test, although other biomarkers are emerging. EED may partly explain the reduced efficacy of oral vaccines in low- and middle-income countries and the increased risk of serious infection seen in children with undernutrition., Conclusions: Despite its potentially significant impacts, it is currently unclear exactly what causes EED and how it can be treated or prevented. Ongoing trials involve nutritional supplements, water and sanitation interventions, and immunomodulators. Further research is needed to better understand this condition, which is of likely crucial importance for child health and development in low- and middle-income settings.

Background and Aims: Successful treatment of patients with irritable bowel syndrome (IBS) often remains elusive. Recent studies in Australia, the United Kingdom and New Zealand have suggested the efficacy of a diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) in the management of these patients. The aims of this study were to determine whether a diet low in FODMAPs improves symptoms in patients with functional gastrointestinal disorders (FGID) in Spain and to analyze the predictors of a good response., Patients and Methods: A prospective study was carried out in consecutive patients with FGID type IBS and functioanl abdominal bloating. At inclusion all patients underwent an assessment through a baseline demographic questionnaire of symptoms of anxiety and depression and quality of life. A hydrogen breath test with lactose and fructose was performed and a low FODMAPs diet was indicated for 2 months by expert dietitians. These tests were taken as a reference. A positive response was defined as an improvement of at least 5 points out of a possible 10 in the symptom questionnaire., Results: We included 30 patients (24 women, 39 [12] years). The response to the low FODMAPs diet was positive in controlling overall symptoms and specific symptoms such as functioanl abdominal bloating, abdominal pain, diarrhea, flatulence, nausea and fatigue in more than 70% of patients (P<.05). By contrast, constipation was controlled in only 48% of patients (P>.05). Adherence to the diet was good in 87% of patients and was a predictor of positive response in the univariate analysis., Conclusions: A diet low in FODMAPs is associated with symptom improvement in patients with IBS and functioanl abdominal bloating. Adherence to the diet was a determining factor., (Copyright © 2014 Elsevier España, S.L.U. and AEEH y AEG. All rights reserved.)

Aim: to study the concentration of vitamins in obese patients after bariatric surgery (BS)., Material and Methods: A total of 100 obese patients aged 19 to 61 years (78 women, 22 men). 20 patients (mean body mass index (BMI)--41.3 ± 8.2 kg/m²) had adjustable gastric banding (AGB), 40 patients--sleeve gastrectomy (SG) and 40--gastric bypass (GB) (mean BMI Group 41.1 ± 17.8 kg/m², and 45.9 ± 6.2 kg/m², respectively). The control group consisted of 10 healthy subjects (BMI--24.9 ± 3.2 kg/m²). We determined the serum level of vitamins B₁, B₂, B₅, B₆, B₉, B₁₂, C, D, niacin, biotin, and retinol-binding protein (RBP) before surgery and 1 year after it., Results: There was a significant reduction ofvitamins C, B₆, B₅, D and RBP both before and after BS. More than half of patients after SG, also had initial reduction of niacin. A year after BS (AGB, SG, GB) the number of patients with deficiency of these vitamins remained the same or increased. Most patients with normal or even elevated levels ofvitamin B₂, niacin and folic acid, has been declining a year after BO. The concentration of the rest of the vitamins also significantly decreased a year after all operations, but their performance remained within normal limits., Conclusion: Levels of vitamins C, B₆ and D were reduced in more than 70% patients with obesity. The number of patients with low levels of vitamin C D, B₆, B₅, niacin, folic acid and RBP increased after BS. BS does not have a significant effect on the metabolism ofvitamins B₁, B₂, B₁₂ and biotin.

Objective: Abdominal symptoms are common after bariatric surgery, and these individuals commonly have upper gut bacterial overgrowth, a known cause of malabsorption. Breath hydrogen determination after oral glucose is a safe and inexpensive test for malabsorption. This study is designed to investigate breath hydrogen levels after oral glucose in symptomatic individuals who had undergone Roux-en-Y gastric bypass surgery., Methods: This is a retrospective study of individuals (n = 63; 60 females; 3 males; mean age 49 years) who had gastric bypass surgery and then glucose breath testing to evaluate abdominal symptoms., Results: Among 63 postoperative individuals, 51 (81%) had a late rise (≥45 minutes) in breath hydrogen or methane, supporting glucose malabsorption; 46 (90%) of these 51 subjects also had an early rise (≤30 minutes) in breath hydrogen or methane supporting upper gut bacterial overgrowth. Glucose malabsorption was more frequent in subjects with upper gut bacterial overgrowth compared to subjects with no evidence for bacterial overgrowth (P < 0.001)., Conclusion: These data support the presence of intestinal glucose malabsorption associated with upper gut bacterial overgrowth in individuals with abdominal symptoms after gastric bypass surgery. Breath hydrogen testing after oral glucose should be considered to evaluate potential malabsorption in symptomatic, postoperative individuals.

Iron deficiency anemia is the most common type of anemia and can cause asthenia, cognitive and functional impairment, and decompensation of underlying diseases. Iron deficiency anemia is not a disease but is the result of a potentially serious medical problem. Consequently, patients should always undergo investigation of the underlying cause. In men and postmenopausal women, the condition is caused by gastrointestinal loss and malabsorption of iron. In this group, recommended procedures are gastroscopy, colonoscopy and serological testing for celiac disease. If the results of these tests are negative, repeat examinations and iron therapy should be considered. In treatment-refractory or recurrent anemia, the small intestine should be investigated. In this case, the procedure of choice is capsule endoscopy. Iron deficiency anemia should always be treated until iron deposits have returned to normal levels. A wide variety of preparations are available, in both oral and parental formulations.

Individuals with extreme obesity who qualify for bariatric surgery are frequently vitamin D deficient before and after surgery. The anatomical changes that occur during some bariatric procedures may lead to decreased absorption of vitamin D, although vitamin D absorption and metabolism has not been quantified or compared across surgeries, and multiple other factors could influence vitamin D status in these individuals. Vitamin D treatment and dosing studies show that there is variability in how individuals respond to supplementation regimens regardless of the bariatric procedure. It is unknown if improving vitamin D status before and/or after bariatric surgery can affect health-related outcomes in this population beyond the traditional roles of vitamin D. Vitamin D has been purported to positively influence a variety of obesity-related comorbidities. Furthermore, in light of the potential role of vitamin D in immunity and inflammation, it seems important to consider the ramifications of vitamin D deficiency in the postbariatric individual in the critical care setting and particularly in the context of aging. Additional research is needed to develop evidence-based guidelines for optimal treatment of vitamin D deficiency in individuals before and after bariatric surgery and to determine the impact of vitamin D repletion on non-bone health-related outcomes in these individuals., (© 2014 American Society for Parenteral and Enteral Nutrition.)

Objective: The growing prevalence of severe obesity, combined with the failure of conservative treatments, has led to a significant spread of bariatric surgical procedures. The aim of this study was to emphasize the need of adequate presurgery patient selection and close follow-up after malabsorptive procedures for bariatric surgery., Methods: The study retrospectively evaluated 25 (20 F, 5 M; mean age 43 ± 13 y) obese patients (mean weight before intervention 134 ± 30.7 kg, body mass index 50.7 ± 10.1 kg/m(2)) attending our outpatient clinical nutrition unit for severe malabsorption and secondary malnutrition after surgical intervention that had been performed outside the regional area., Results: All patients received personalized dietetic indications; in 12 of 25 (48%) cases integrated by oral protein supplements and in 5 of 25 (20%) by medium chain triglycerides. According to screening exams, patients were prescribed oral/parenteral iron, vitamins A, B group, D, and folate supplementation. In 14 of 25 (56%) patients, parenteral hydration and in 4 of 25 (16%), long-term parenteral nutrition was required. Five patients required hospitalization for severely complicated protein-energy malnutrition., Conclusion: Nutritional deficiencies are common after malabsorptive procedures for bariatric surgery; these can be present or latent before surgery, frequently going unrecognized and/or inadequately treated particularly when patients are not strictly followed up by the operating center. Despite the adequate-even intensive-intervention, clinical nutritional status moderately improved in all patients., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Hypogammaglobulinemia, a form of primary immunodeficiency, is an uncommon condition. Gastrointestinal (GI) symptoms may be the only presentation. A series of 22 patients who presented with GI symptoms and were diagnosed with hypogammaglobulinemia is presented. Chronic diarrhea was the presentation in majority (90.9 %) of patients. Malabsorption was identified in 87.5 % of patients followed by weight loss (59.0 %), abdominal pain (27.2 %), and oral ulcers (4.5 %). The median duration of symptoms prior to diagnosis was 4 years, range being 6 months to 23 years. Evaluation revealed opportunistic infections including Giardia lamblia in 31.8 % and Cryptosporidium parvum, Isospora belli, Cytomegalovirus and Aeromonas in 4.5 % each. Serum globulins were low in all patients. Duodenal biopsy showed paucity of plasma cells in 45 %, villous atrophy in 35 % and nodular lymphoid hyperplasia in 30 % patients. Though uncommon, hypogammaglobulinemia is associated with GI disease. The possibility of a primary immunodeficiency should be considered in patients presenting with GI symptoms and low serum globulin.

Celiac disease (CD) is a chronic disease causing the inflammation of the proximal small intestine, in genetically predisposed individuals. This is triggered by the consumption of the gluten protein and the side effects of the disease are mitigated by a lifelong gluten-free diet (GFD) treatment. The predominant consequence of CD is malnutrition due to malabsorption (with diarrhea, weight loss, nutritional deficiencies, and altered blood parameters), especially in patients who do not show strict adherence to GFD treatment. Recent evidence shows that, despite a lifelong GFD, some functional disorders persist, such as compromised gallbladder function and motility, exocrine pancreatic insufficiency, increased gut permeability, small-intestinal bowel overgrowth, nonalcoholic fatty liver disease (NAFLD), lactose intolerance, and milk allergy. These abnormalities may predispose to the occurrence of overweight and obesity even in CD patients. This review focuses on the principal functional and metabolic disorders in both treated and untreated CD, ranging from alterations of the gastrointestinal system to impaired glucose and lipid metabolism and insulin secretion with the aim of providing new implications beyond a GFD, for an ad hoc nutrition treatment in these patients.

Background and Aims: Bile acid malabsorption (BAM)-associated diarrhea is an important clinical issue in patients with Crohn's disease (CD). We analyzed the efficacy and safety of the bile acid sequestrant colesevelam for treatment of BAM-associated diarrhea in CD patients in a randomized, double-blind, placebo-controlled study., Methods: The primary endpoint was the proportion of patients with >30% reduction of liquid stools/day from baseline to termination visit at week 4. Secondary endpoints were reduction of the number of liquid stools/day, improvement of stool consistency and quality of life., Results: 26 patients were analyzed in the intention-to-treat (ITT) analysis. The primary endpoint was reached by 10 patients (69.7%) in the colesevelam group compared to 3 patients (27.3%) in the placebo group (risk difference RD=.394, 95%CI:[-0.012; 0.706]; P=.0566). In the per-protocol analysis (n=22), the risk difference was statistically significant (RD=.470, 95%CI:[0.018; 0.788], P(H0: RD=0)=0.0364; 95% CI:[1.3;54.7]). Regarding secondary endpoints, in the ITT population colesevelam-treated patients had a significant reduction of liquid stools/day at week 4 (median 5.0 to 2.0; P=0.01), while patients treated with placebo had no significant reduction (median 4.0 to 3.0; P=0.42). Significantly more patients in the colesevelam group had improvement of stool consistency of at least one level in the Bristol stool chart, as compared to the placebo group (P=0.003)., Conclusions: We found significant differences in favor for colesevelam treatment compared to placebo treatment for CD patients with BAM regarding the reduction of the number of liquid stools/day and stool consistency. ClinicalTrials.gov number: NCT01203254., (Copyright © 2014 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.)

Cystic fibrosis can affect food digestion and nutrient absorption. The underlying mutation of the cystic fibrosis trans-membrane regulator gene depletes functional cystic fibrosis trans-membrane regulator on the surface of epithelial cells lining the digestive tract and associated organs, where Cl(-) secretion and subsequently secretion of water and other ions are impaired. This alters pH and dehydrates secretions that precipitate and obstruct the lumen, causing inflammation and the eventual degradation of the pancreas, liver, gallbladder and intestine. Associated conditions include exocrine pancreatic insufficiency, impaired bicarbonate and bile acid secretion and aberrant mucus formation, commonly leading to maldigestion and malabsorption, particularly of fat and fat-soluble vitamins. Pancreatic enzyme replacement therapy is used to address this insufficiency. The susceptibility of pancreatic lipase to acidic and enzymatic inactivation and decreased bile availability often impedes its efficacy. Brush border digestive enzyme activity and intestinal uptake of certain disaccharides and amino acids await clarification. Other complications that may contribute to maldigestion/malabsorption include small intestine bacterial overgrowth, enteric circular muscle dysfunction, abnormal intestinal mucus, and intestinal inflammation. However, there is some evidence that gastric digestive enzymes, colonic microflora, correction of fatty acid abnormalities using dietary n-3 polyunsaturated fatty acid supplementation and emerging intestinal biomarkers can complement nutrition management in cystic fibrosis., (Copyright © 2014 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Along with the increasing prevalence of obesity surgical methods of treatment are becoming more accessible. The success of bariatric surgery results from the failure of conservative treatment of obesity through diet, exercises and behavioral changes. Such behaviors, including less effective drug therapy, are responsible for rather small and unstable weight reduction. In contrast, surgical treatment restrictions limiting the amount of food intake, excluding treatments and mixed treatments usually give a spectacular effect, though it is not always consistent with the previous assumptions. Most of us, however, do not realize the risk of the consequences that these treatments bring. The change of the absorption of oral medications, vitamins, microelements, often change the way they are metabolized and it forces ones to change the form of the drug, the way they are taken, which undoubtedly is associated with higher costs of later treatment. Many clinicians are unaware of the need for lifelong supplementation of some vitamins and microelements, as well as the need to modify pharmacotherapy in patients who have undergone this type of operations. This article presents examples of the best known and described changes in the absorption of drugs and micronutrients and explains how well oriented the internist ought to be when qualifying a patient to undergo this type of treatment. The described topic is interesting, but also controversial due to the fact that it corresponds closely with the surgical specialties, quite spectacular in their effects and behavioral specializations, that in many years time will be looking after the patient who underwent the surgery, but is still sick.

A 37-year-old patient with type 1 diabetes had been recently diagnosed with collagenous colitis (CC) after sigmoidoscopy. She rapidly progressed from a fortnight of watery diarrhoea, to a malabsorptive state with severe dehydration and acute kidney injury. This necessitated admission to an intensive care unit for emergency dialysis. She was subsequently diagnosed with collagenous enterocolitis affecting gastric, small bowel and colonic mucosa which required systemic steroid therapy. Physicians caring for patients with CC should be aware of the potential extreme manifestations of upper gastrointestinal collagenous deposition., (2014 BMJ Publishing Group Ltd.)

Microvillus inclusion disease (MVID) is a severe form of congenital diarrhea that arises from inactivating mutations in the gene encoding myosin Vb (MYO5B). We have examined the association of mutations in MYO5B and disruption of microvillar assembly and polarity in enterocytes. Stable MYO5B knockdown (MYO5B-KD) in CaCo2-BBE cells elicited loss of microvilli, alterations in junctional claudins, and disruption of apical and basolateral trafficking; however, no microvillus inclusions were observed in MYO5B-KD cells. Expression of WT MYO5B in MYO5B-KD cells restored microvilli; however, expression of MYO5B-P660L, a MVID-associated mutation found within Navajo populations, did not rescue the MYO5B-KD phenotype but induced formation of microvillus inclusions. Microvilli establishment required interaction between RAB8A and MYO5B, while loss of the interaction between RAB11A and MYO5B induced microvillus inclusions. Using surface biotinylation and dual immunofluorescence staining in MYO5B-KD cells expressing mutant forms of MYO5B, we observed that early microvillus inclusions were positive for the sorting marker SNX18 and derived from apical membrane internalization. In patients with MVID, MYO5B-P660L results in global changes in polarity at the villus tips that could account for deficits in apical absorption, loss of microvilli, aberrant junctions, and losses in transcellular ion transport pathways, likely leading to the MVID clinical phenotype of neonatal secretory diarrhea.

Objective: The objective is to present an update on the diagnosis and treatment of hypovitaminosis D, based on the most recent scientific evidence., Materials and Methods: The Department of Bone and Mineral Metabolism of the Brazilian Society of Endocrinology and Metabology (SBEM) was invited to generate a document following the rules of the Brazilian Medical Association (AMB) Guidelines Program. Data search was performed using PubMed, Lilacs and SciELO and the evidence was classified in recommendation levels, according to the scientific strength and study type., Conclusion: A scientific update regarding hypovitaminosis D was presented to serve as the basis for the diagnosis and treatment of this condition in Brazil.

Carbohydrate malabsorption is a frequent but underestimated cause of unexplained gastrointestinal symptoms like meteorism, flatulence, pain and diarrhea. By means of hydrogen and/or methane breath test after ingestion of the respective carbohydrate it can be identified and diagnosed easily, fast and reliably by successful nutritional therapy. Besides the well known complaints caused by lactose and fructose malabsorption, other fermentable oligo-, di-, or monosaccharides and polyols (akronym: FODMAP) can cause abdominal discomfort and IBS-like symptoms. In addition to lactose (dairy products) and fructose (apples, pears, mango, watermelon), FODMAPs comprise galactans (legumes), fructans (wheat, onions, garlic, artichoke) and the artificial sweeteners sorbitol, mannitol, maltitol and xylitol (sugar free candy, light products). A general restriction of all FODMAP components can be beneficial in relieving symptoms and improving quality of life in patients with functional gastrointestinal complaints., (© Georg Thieme Verlag KG Stuttgart · New York.)

Non-celiac gluten sensitivity (NCGS) is an emerging disorder characterized by intestinal and extra-intestinal symptoms related to the ingestion of gluten-containing food in non-celiac patients. Its prevalence has been estimated to be six to ten-times higher than that of celiac disease (CD). A gluten-free diet is the most widely recommended therapy, but the causative agent remains unknown and there are no consensus diagnostic criteria. Recent studies on NCGS have included patients with possibly overlooked minor CD and diarrhea-predominant irritable bowel syndrome without self-reported gluten intolerance, but showing a response to a gluten-free diet. Furthermore, FODMAPs (Fermentable Oligosaccharides, Disaccharides, Monosaccharides And Polyols) have recently been postulated as the culprit component for NCGS in wheat, instead of gluten. This review updates evidence on the pathophysiology of NCGS and the efficacy of different dietary interventions in its treatment, stressing the need for proper screening for CD before a diagnosis of NCGS is made., (Copyright © 2013 Elsevier España, S.L. and AEEH y AEG. All rights reserved.)

Background: The etiology of small intestinal bacterial overgrowth (SIBO) is diverse and frequently multi-factorial. SIBO is thought to result from structural changes of the gastrointestinal tract, disordered peristalsis of the stomach and/or small intestine, or a disruption of the normal mucosal defenses of the small intestine. Alcoholics are reported to have higher rates of SIBO, as diagnosed by jejunal aspirate; however, no data are available on the association between moderate alcohol consumption and SIBO., Aim: To evaluate the association between moderate alcohol consumption and SIBO and identify risk factors for SIBO using the lactulose breath test (LBT)., Methods: A retrospective chart review was completed for 210 consecutive patients who underwent the LBT between 2008 and 2010. We reviewed demographic data, including age, race, body mass index, alcohol and tobacco history, medication use, comorbid medical conditions, and history of abdominal surgery., Results: The study included 196 patients (68 % female; mean age 55 years), 93 of whom had a positive LBT (47.4 %). Of those patients who consumed a moderate amount of alcohol, 58 % had a positive LBT, compared to 38.9 % of abstainers (P = 0.008). Those with a history of cholecystectomy had significantly lower rates of a positive LBT than those who had not (33.3 vs. 51.7 % respectively; P = 0.031). Neither proton pump inhibitor (PPI) use nor tobacco use was associated with a positive LBT., Conclusion: In this retrospective review, moderate alcohol consumption was a strong risk factor for SIBO. Cholecystectomy appeared to be protective against SIBO. Neither PPI use nor tobacco use was associated with an increased risk of SIBO.

Objective: To determine symptoms of small intestinal bacterial overgrowth (SIBO) in gastroparesis patients., Methods: Patients undergoing LBT (lactulose breath test) for evaluation of SIBO were included. LBT was considered positive on the basis of three conventional criteria: (1) hydrogen level increase >20 ppm above baseline by 90 min (H2@90min); (2) dual hydrogen peaks (>10 ppm increase over baseline before second peak >20 ppm (DPHBT); and (3) breath methane increase of >20 ppm above baseline by 90 min. Results of gastric emptying scintigraphy (GES) were recorded. Patients completed the Patient Assessment of Upper Gastrointestinal Disorders-Symptom Severity Index., Results: Of 740 patients who underwent LBT from December 2009 to August 2011, 471 underwent GES, with 201 having delayed GES. Of patients with delayed GES who underwent LBT 87 % were female, 23 % diabetic, 49 % used gastric acid suppressants, 29 % used opiate analgesics, 35 % used pro-motility medications, and 27 % had a history of gastrointestinal surgery. Overall, 79 (39 %) patients with gastroparesis had evidence of SIBO by LBT: 30 (15 %) had positive H2@90min, 53 (26 %) positive DPHBT, and 6 (3 %) positive breath methane test. In gastroparesis patients with positive H2@90min, there was increased severity of bloating (3.80 ± 0.20 vs 3.29 ± 0.12; P = 0.02), early satiety (3.57 ± 0.27 vs 3.05 ± 0.13; P = 0.045), and postprandial fullness (4.20 ± 0.18 vs 3.52 ± 0.12; P < 0.01) compared with negative H2@90min patients. No significant difference in symptom severity was seen between positive and negative DPHBT gastroparesis patients., Conclusion: In our cohort, 39 % of gastroparesis patients tested positive for SIBO by LBT. Positive H2@90min testing by LBT was associated with increased symptoms of bloating and excessive fullness during and after meals.

A 57-year-old Japanese man was admitted to our hospital with diarrhea, weight loss and malabsorption. Due to a high serum IgA level, we suspected α-heavy chain disease (α-HCD). However, no monoclonal IgA was detected on protein electrophoresis or immunofixation. Immunohistochemical staining of intestinal biopsy specimens showed proliferation of CD138(+)IgA(+) cells, compatible with a diagnosis of α-HCD. Most α-HCD patients exhibit M-proteins in the serum on electrophoresis or immunoelectrophoresis; however, some patients lack detectable M-proteins, similar to our patient. Therefore, when α-HCD is suspected based on the clinical features, immunohistochemistry is required to make a diagnosis.

Pancreatic exocrine insufficiency (PEI) is one of the long-term consequences of chronic pancreatitis (CP). Majority of patients with PEI were undiagnosed or undertreated. Inadequately treated or subclinical severe PEI causes malnutrition and may pose the patients at risk of premature atherosclerosis and cardiovascular events. Indication of pancreatic enzyme replacement therapy (PERT) is patients with severe PEI, as indicated by the presence of steatorrhea, diarrhea, weight loss, fecal fat > 7 g/day, (13) C-mixed triglyceride breath test < 29%, fecal elastase < 100 ug/g stool, imaging or endoscopic findings of pancreatic ductal dilatation or calculi, and eight endosonographic criteria of CP. The mainstay treatment of PEI is PERT. Dietary fat restriction is unnecessary. PERT with lipase > 40,000 U per meal is recommended. Enteric-coating may be preferred to conventional enzymes because of the availability of high-dose preparations and no need of acid suppression co-therapy. Administration of enzymes with meals is proven to be the most effective regimen. Response to PERT should be measured by the improvement of patients' symptoms, nutritional status, and, in selected cases, by fecal fat or (13) C-mixed triglyceride breath test. Patients unresponsive to PERT should be checked for compliance, increase the dose of lipase to 90,000 units/meal or co-therapy with proton pump inhibitor. In patient with previous gastrointestinal surgery that may interfere enzyme-food mixing, opening the capsules and administering the enzyme granules with meals. Finally, search for small intestinal bacterial overgrowth syndrome and other causes of small bowel malabsorption., (© 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.)

The aim of our study was to compare bone mineral density (BMD) a year after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) in age- and body mass index-matched women. In 33 morbidly obese women undergoing RYGB and 33 undergoing SG, plasma determinations of calcium, parathyroid hormone (PTH), 25-hydroxyvitamin D (25(OH) D3), and insulin-like growth factor-I (IGF-I) were made prior to and at 12 months after surgery. Dual-energy X-ray absorptiometry was performed in all patients 1 year after surgery. BMD at the femoral neck and the lumbar spine 1 year after surgery was similar in women undergoing RYGB and SG (1.01 ± 0.116 vs. 1.01 ± 0.122 g/cm(2), p = 0.993; 1.05 ± 0.116 vs. 1.08 ± 0.123 g/cm(2), p = 0.384). The percentage of patients with osteopenia and osteoporosis was not different between groups. In the linear regression analysis, age (β = -0.628, p = 0.034) and lean mass 12 months after surgery (β = 0.424, p = 0.021) were found to be the main determinants of femoral neck BMD. Age (β = -0.765, p = 0.025), menopause (β = -0.898, p = 0.033), and lean mass (β = 0.615, p = 0.023) were determinants of BMD at the lumbar spine. No influence was found between low bone mass and type of surgery, plasma PTH, 25(OH) D3, or IGF-I. The effect of RYGB and SG on BMD was comparable a year after surgery. Menopausal women were at a higher risk of having low bone mass, but the presence of osteoporosis was uncommon.

Background: Adverse food reactions (AFR) have has recently attracted increased attention from the media and are now more commonly reported by patients. Its classification, diagnostic evaluation, and treatment are complex and present a considerable challenge in clinical practice. Non-immune-mediated types of food intolerance have a cumulative prevalence of 30% to 40%, while true (immune-mediated) food allergies affect only 2% to 5% of the German population., Method: We selectively searched the literature for pertinent publications on carbohydrate malabsorption, with special attention to published guidelines and position papers., Results: Carbohydrate intolerance can be the result of a rare, systemic metabolic defect (e.g., fructose intolerance, with a prevalence of 1 in 25,000 persons) or of gastrointestinal carbohydrate malabsorption. The malabsorption of simple carbohydrates is the most common type of non-immune-mediated food intolerance, affecting 20% to 30% of the European population. This condition is caused either by deficient digestion of lactose or by malabsorption of fructose and/or sorbitol. Half of all cases of gastrointestinal carbohydrate intolerance have nonspecific manifestations, with a differential diagnosis including irritable bowel syndrome, intolerance reactions, chronic infections, bacterial overgrowth, drug side effects, and other diseases. The diagnostic evaluation includes a nutritional history, an H2 breath test, ultrasonography, endoscopy, and stool culture., Conclusion: The goals of treatment for carbohydrate malabsorption are to eliminate the intake of the responsible carbohydrate substance or reduce it to a tolerable amount and to assure the physiological nutritional composition of the patient's diet. In parallel with these goals, the patient should receive extensive information about the condition, and any underlying disease should be adequately treated.

Roux-en-Y gastric bypass (RYGB) surgery leads to bone loss in humans, which may be caused by vitamin D and calcium malabsorption and subsequent secondary hyperparathyroidism. However, because these conditions occur frequently in obese people, it is unclear whether they are the primary causes of bone loss after RYGB. To determine the contribution of calcium and vitamin D malabsorption to bone loss in a rat RYGB model, adult male Wistar rats were randomized for RYGB surgery, sham-operation-ad libitum fed, or sham-operation-body weight-matched. Bone mineral density, calcium and phosphorus balance, acid-base status, and markers of bone turnover were assessed at different time points for 14 wk after surgery. Bone mineral density decreased for several weeks after RYGB. Intestinal calcium absorption was reduced early after surgery, but plasma calcium and parathyroid hormone levels were normal. 25-hydroxyvitamin D levels decreased, while levels of active 1,25-dihydroxyvitamin D increased after surgery. RYGB rats displayed metabolic acidosis due to increased plasma lactate levels and increased urinary calcium loss throughout the study. These results suggest that initial calcium malabsorption may play a key role in bone loss early after RYGB in rats, but other factors, including chronic metabolic acidosis, contribute to insufficient bone restoration after normalization of intestinal calcium absorption. Secondary hyperparathyroidism is not involved in postoperative bone loss. Upregulated vitamin D activation may compensate for any vitamin D malabsorption.

Coeliac disease is an autoimmune disorder triggered by gluten intake, causing intestinal inflammation and mucosal damage commonly associated with the malabsorption of nutrients and ferropenic anaemia. The present study evaluates the effects of the oral administration of Bifidobacterium longum CECT 7347 on gliadin-mediated alterations in hepatic Fe deposition and Hb concentration, liver transferrin receptor (TfR)-2, IL-6, TNF-α and hepcidin (Hamp) expression (mRNA), and active hepcidin peptide production by liquid chromatography–MS/MS. Weanling rats, sensitised or not with interferon (IFN)-γ, were fed with gliadins and/or the bifidobacterial strain. Gliadin feeding increased hepatic Fe deposition; however, only gliadin-fed sensitised animals showed lower Hb concentrations than the controls. TfR2 expression decreased after gliadins were fed to both sensitised and non-sensitised animals,and restored by the administration of B. longum. These observations were accompanied by increases in IL-6 expression levels in all the treatment groups; however, TNF-α expression only increased significantly in animals fed gliadins alone or together with B. longum if they had previously been sensitised with IFN-γ. Liver expression levels of Hamp diminished in all cases to the lowest values in animals sensitised with IFN-γ after being fed with gliadins and/or bifidobacteria. In these animals, plasma Hamp active peptide concentrations significantly increased when compared with the controls. Significant correlations were calculated between Hamp expression and liver Fe contents (liver Fe = 1/0·0032 + 0·032 x Hamp(exp)), and Hb concentrations (Hb = 11·49 + 10·13 x (Hamp(exp))1/2). These data indicate that oral administration of B. longum ameliorates gliadin-mediated perturbations in liver Fe deposition and mobilisation.

The objective of this study was to describe the main factors related to the installation and/or aggravation of vitamin D deficiency (VDD) and its clinical consequences in pregnant women after bariatric surgery. An electronic search on VDD in pregnancy and after bariatric surgery was conducted in publications from 1998 until 2012 that presented studies performed in humans. We provided an overview of VDD after bariatric surgery, in pregnancy, and in pregnancy in women who underwent bariatric surgery. In view of the high percentage of VDD postoperatively and the role of this vitamin in pregnancy, we recommend the investigation of vitamin D nutritional status in prenatal care.

Short bowel syndrome (SBS) refers to the clinical consequences resulting from loss of small bowel absorptive surface area due to surgical resection or bypass. The syndrome is characterized by maldigestion, malabsorption, and malnutrition. Survival of patients with SBS is dependent on adaptation in the remaining bowel and a combination of pharmacologic and nutrition therapies. Individual plans of care are developed based on the length and sites of remaining bowel, the degree of intestinal adaptation, and the patient's ability to adhere to the medication and dietary regimens. Antisecretory and antidiarrheal medications are prescribed to slow intestinal transit times and optimize fluid and nutrient absorption. Based on postsurgical anatomy, enteral feedings, parenteral infusions, complex diet plans, and vitamin and mineral supplementation are used in various combinations to nourish patients with SBS. In the acute care setting, registered dietitians (RDs) assist with infusion therapy, diet education, and discharge planning. Long-term, as the small intestine adapts, RDs revise the nutrition care plan and monitor for nutrient deficiencies, metabolic bone disease, and anemia. The frequent monitoring and revision of care plans, plus the appreciable benefits from proper medical nutrition therapy, make this patient population extremely challenging and rewarding for RDs to manage. This article provides a brief, case study-based overview of the medical and nutrition management of SBS., (Copyright © 2013 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of the present study was to determine the prevalence and predisposing factors for vitamin D deficiency and low bone mineral density (BMD) in patients with intestinal failure (IF)., Methods: A retrospective review of patients with IF managed at the Cincinnati Children's Hospital Medical Center. IF was defined as history of parenteral nutrition (PN) >30 days. Vitamin D deficiency was defined as serum 25-hydroxyvitamin D (25 (OH) D) <20 ng/dL. Reduced BMD was defined using dual x-ray absorptiometry z score ≤-2. A binary logistic regression model was used to test for association of significant risk factors and the outcome variables after univariate analyses., Results: One hundred and twenty-three patients with median age of 4 years (range 3-22 years) were evaluated. Forty-nine (39.8%) patients had at least a documented serum 25 (OH) D deficiency during the study interval, whereas 10 of 80 patients (12.5%) with dual x-ray absorptiometry scans completed had a low BMD z score. Age at study entry was associated with both 25 (OH) D deficiency (P = 0.01) and low BMD z score (P = 0.03). Exclusive PN at study entry was associated with reduced bone mass (P = 0.03). There was no significant association between vitamin D deficiency and low BMD z score (P = 0.31)., Conclusions: The risk of 25 (OH) D deficiency and low BMD z score increases with age among patients with IF. Strategies for monitoring and preventing abnormal bone health in older children receiving exclusive PN need to be developed and evaluated.

Moderate/severe obesity is on the rise in the United States. Weight management includes bariatric surgery, which is effective and can alleviate morbidity and mortality from obesity-associated diseases. However, many individuals are dealing with nutritional complications. Risk factors include: 1) preoperative malnutrition (e.g., vitamin D, iron); 2) decreased food intake (due to reduced hunger and increased satiety, food intolerances, frequent vomiting); 3) inadequate nutrient supplementation (due to poor compliance with multivitamin/multimineral regimen, insufficient amounts of vitamins and/or minerals in supplements); 4) nutrient malabsorption; and 5) inadequate nutritional support (due to lack of follow-up, insufficient monitoring, difficulty in recognizing symptoms of deficiency). For some nutrients (e.g., protein, vitamin B-12, vitamin D), malnutrition issues are reasonably addressed through patient education, routine monitoring, and effective treatment strategies. However, there is little attention paid to other nutrients (e.g., zinc, copper), which if left untreated may have devastating consequences (e.g., hair loss, poor immunity, anemia, defects in neuro-muscular function). This review focuses on malnutrition in essential minerals, including calcium (and vitamin D), iron, zinc, and copper, which commonly occur following popular bariatric procedures. There will be emphasis on the complexities, including confounding factors, related to screening, recognition of symptoms, and, when available, current recommendations for treatment. There is an exceptionally high risk of malnutrition in adolescents and pregnant women and their fetuses, who may be vulnerable to problems in growth and development. More research is required to inform evidence-based recommendations for improving nutritional status following bariatric surgery and optimizing weight loss, metabolic, and nutritional outcomes.

Background and Aim: A major use of breath hydrogen testing is to assess absorptive capacity for sugars to assist dietary design for management of gut symptoms. Qualitative reporting takes no account of the vigor of hydrogen response and provides little insight into degrees of malabsorption. This study aimed to describe a semiquantitative reporting method and to compare results with those reported qualitatively., Methods: In consecutive Caucasian patients with Crohn's disease (n = 87), ulcerative colitis (59), functional gastrointestinal disorders (FGID) (162), and healthy controls (76), area under the curve was calculated for lactulose (15 g). This was compared with that for lactose (50 g) and fructose (35 g). Degree of malabsorption was categorized into arbitrary groups., Results: Semiquantitative results for ≥ 30% (designated "convincing") malabsorption was most similar to those using a qualitative cutoff value of 20 ppm, but in 38% and 21% of patients, the classification of malabsorption (nil or clinically significant) changed for fructose and lactose, respectively. Using a cutoff of 10 ppm, 49% and 5% were classified differently. Crohn's disease had a higher prevalence (42%) of convincing fructose malabsorption than controls (24%) or patients with FGID (33%) (P < 0.02). Highest prevalence of convincing lactose malabsorption (38%) was in ulcerative colitis, greater than controls (18%) and FGID (18%) (P < 0.02)., Conclusions: Semiquantitative assessment provides different results with different clinical implications in more than one third of patients, but disease-related alterations in prevalence are similar to those defined qualitatively. This method may be preferable because it lessens the confounding influence of the vigor of the hydrogen response., (© 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.)

Background: Iron deficiency anemia (IDA) is a common finding in patients after bariatric surgery. The cause is multifactorial including reduced oral iron intake and malabsorption. While many patients can be managed with oral supplements, parenteral iron may be needed to restore and maintain iron stores., Methods: Subjects who had previous bariatric surgery and had participated in phase 3 industry-sponsored clinical trials designed to assess the safety and/or efficacy of intravenous (IV) ferric carboxymaltose (FCM) were retrospectively selected from the databases of each of these studies. Demographic data, efficacy measures [hemoglobin, ferritin, and transferrin saturation (TSAT)], and adverse events were compared between FCM and other agents utilized as comparators in the trials., Results: Two hundred eighty-one subjects from the intention to treat (ITT) population were included (mean age 49 years, BMI 33 kg/m(2), including 253 females). FCM had similar or improved efficacy (p < 0.05) in terms of increasing hemoglobin, ferritin, and TSAT values when compared to other iron products used as standard of care for IDA. The incidence of adverse events in the FCM patients (n = 123) versus patients receiving any IV iron (n = 126) was 61 and 56.3 %, respectively. The adverse events were similar in both groups with the exception of a transient decrease in serum phosphate which was observed more frequently in the FCM group., Conclusions: These data in post-bariatric surgery IDA patients suggest that FCM is a safe and effective alternative to existing iron products permitting higher and thus less frequent individual doses.

Background: The study of faeces offers a unique opportunity to observe cooperation between the microbiome and the metabolism of mammalian hosts, an essential element in the study of the human metabolome. In the present study, a global metabolomics approach was used to identify metabolites differentially excreted in the faeces of cirrhotic patients compared to controls., Methods: Seventeen cirrhotic patients and 24 healthy individuals were recruited. Faecal metabolites were detected through non-targeted reversed-phase ultra-performance liquid chromatography coupled to electrospray ionization quadrupole time-of-flight mass spectrometry., Results: A total of 9215 peaks were detected. Using unequal variance t-tests, 2393 peaks were observed with P≤0.05, approximately 74.0% of which were due to decreased faecal metabolite concentrations in liver cirrhosis vs. healthy controls. Integrating multivariate data analyses, we identified six major groups of metabolites. Relative levels of identified metabolites were as follows: strong increase in lysophosphatidylcholines, aromatic amino acids, fatty acids, and acylcarnitines, and a dramatic decrease in bile acids and bile pigments., Conclusion: With severe hepatic injury in patients with liver cirrhosis, malabsorption occurs along with disorders of fatty acid metabolism, potentially due to changes in gut microflora., (Copyright © 2013 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Weight loss following esophagectomy is a management challenge for all patients. It is multifactorial with contributing factors including loss of gastric reservoir, rapid small bowel transit, malabsorption, and adjuvant chemotherapy. The development of a postoperative malabsorption syndrome, as a result of exocrine pancreatic insufficiency (EPI), is recognized in a subgroup of patients following gastrectomy. This has not previously been documented following esophageal resection. EPI can result in symptoms of flatulence, diarrhea, steatorrhea, vitamin deficiencies, and weight loss. It therefore has the potential to pose a significant level of morbidity in postoperative patients. There is some evidence that patients with proven EPI (fecal elastase-1 < 200 μg/g) may benefit from a trial of pancreatic enzyme replacement therapy (PERT). We observed symptoms compatible with EPI in a subgroup of patients following esophagectomy. We hypothesized that this was contributing to malabsorption and malnutrition in these patients. To investigate this, fecal elastase-1 was measured in postoperative patients, and in those with proven EPI, a trial of PERT was commenced in combination with specialist dietary education. At routine postoperative follow-up, which included assessment by a specialist dietitian, those patients with symptoms suggestive of malabsorption were given the opportunity to have their fecal elastase-1 measured. PERT was then offered to patients with fecal elastase-1 less than 200 μg/g (EPI) as well as those in the 200-500 μg/g range (mild EPI) with more severe symptoms. Fecal elastase-1 was measured in 63 patients between June 2009 and January 2011 at a median of 4 months (range 1-42) following surgery. Ten patients had fecal elastase-1 less than 200 μg/g, and all had failed to maintain preoperative weight. All accepted a trial of PERT. Nine (90%) had symptomatic improvement, and seven (70%) increased their weight. Thirty-nine patients had a fecal elastase-1 in the 200-500 μg/g range. Twelve were given a trial of PERT based on level of symptoms, five (42%) reported an improvement in symptoms, but only two (17%) gained weight. Our early results support the observation that EPI is a factor contributing to postoperative morbidity in patients recovering from esophagectomy and that these patients can benefit from a trial of PERT. Our study has limitations, and a formal trial is required to evaluate the impact of EPI and PERT following esophagectomy. Currently, our practice is to measure fecal elastase-1 in any patient with unexplained weight loss or symptoms of malabsorption. In patients with proven EPI or those who are symptomatic with mild EPI, a trial of PERT should be offered and symptoms reassessed., (© 2012 Copyright the Authors. Journal compilation © 2012, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.)

Cobalamin malabsorption accompanied by selective proteinuria is an autosomal recessive disorder known as Imerslund-Gräsbeck syndrome in humans and was previously described in dogs due to amnionless (AMN) mutations. The resultant vitamin B12 deficiency causes dyshematopoiesis, lethargy, failure to thrive, and life-threatening metabolic disruption in the juvenile period. We studied 3 kindreds of border collies with cobalamin malabsorption and mapped the disease locus in affected dogs to a 2.9Mb region of homozygosity on canine chromosome 2. The region included CUBN, the locus encoding cubilin, a peripheral membrane protein that in concert with AMN forms the functional intrinsic factor-cobalamin receptor expressed in ileum and a multi-ligand receptor in renal proximal tubules. Cobalamin malabsorption and proteinuria comprising CUBN ligands were demonstrated by radiolabeled cobalamin uptake studies and SDS-PAGE, respectively. CUBN mRNA and protein expression were reduced ~10 fold and ~20 fold, respectively, in both ileum and kidney of affected dogs. DNA sequencing demonstrated a single base deletion in exon 53 predicting a translational frameshift and early termination codon likely triggering nonsense mediated mRNA decay. The mutant allele segregated with the disease in the border collie kindred. The border collie disorder indicates that a CUBN mutation far C-terminal from the intrinsic factor-cobalamin binding site can abrogate receptor expression and cause Imerslund-Gräsbeck syndrome., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose of Review: Fructose malabsorption is associated with gastrointestinal symptoms. This review examines new findings on the physiology, assessment and therapy of fructose malabsorption in functional gastrointestinal disorders., Recent Findings: Additional GLUT transport mechanisms that regulate fructose absorption might be involved in symptom adaptation to high-fructose diets. Although glucose is known to facilitate fructose absorption, erythritol promotes malabsorption. The methodologies of fructose breath testing and its clinical utility have been questioned by findings of unrealistic testing dose and poor reproducibility. Although fructose restriction appears to benefit children with functional abdominal pain, fructose restriction itself may not be the key player. In irritable bowel syndrome, fructose restriction within a diet low in other fermentable carbohydrates fermentable, oligosaccharide, disaccharide monosaccharide and polyols produced good symptom control compared with habitual diet, but such therapy resulted in significantly reduced bifidobacteria. Fructose absorption and subsequently, abdominal pain and nausea are improved by a novel enzyme therapy that converts fructose to glucose for absorption., Summary: New insights into factors affecting fructose absorption may have therapeutic applications. Doubts surrounding clinical utility of fructose breath testing are emerging. Although restriction of fructose and other fermentable, oligosaccharide, disaccharide monosaccharide and polyols have efficacy for functional gastrointestinal symptoms, potentially negative effects on microbiota deserve attention.

Background & Aims: Proprotein convertase 1/3 (PC1/3) deficiency, an autosomal-recessive disorder caused by rare mutations in the proprotein convertase subtilisin/kexin type 1 (PCSK1) gene, has been associated with obesity, severe malabsorptive diarrhea, and certain endocrine abnormalities. Common variants in PCSK1 also have been associated with obesity in heterozygotes in several population-based studies. PC1/3 is an endoprotease that processes many prohormones expressed in endocrine and neuronal cells. We investigated clinical and molecular features of PC1/3 deficiency., Methods: We studied the clinical features of 13 children with PC1/3 deficiency and performed sequence analysis of PCSK1. We measured enzymatic activity of recombinant PC1/3 proteins., Results: We identified a pattern of endocrinopathies that develop in an age-dependent manner. Eight of the mutations had severe biochemical consequences in vitro. Neonates had severe malabsorptive diarrhea and failure to thrive, required prolonged parenteral nutrition support, and had high mortality. Additional endocrine abnormalities developed as the disease progressed, including diabetes insipidus, growth hormone deficiency, primary hypogonadism, adrenal insufficiency, and hypothyroidism. We identified growth hormone deficiency, central diabetes insipidus, and male hypogonadism as new features of PCSK1 insufficiency. Interestingly, despite early growth abnormalities, moderate obesity, associated with severe polyphagia, generally appears., Conclusions: In a study of 13 children with PC1/3 deficiency caused by disruption of PCSK1, failure of enteroendocrine cells to produce functional hormones resulted in generalized malabsorption. These findings indicate that PC1/3 is involved in the processing of one or more enteric hormones that are required for nutrient absorption., (Copyright © 2013 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Pellagra is a rare condition that has been known for many years to be related to niacin deficiency. Clinically known as the 4 "D" symptoms for dermatitis, diarrhea, dementia, and even death, skin changes remain one of the most important features of this pathology, leading frequently to the diagnosis. Pellagra is mostly seen in poor populations with a deficient diet; still, it is sporadically observed in developed countries, usually in association with digestive disorders. We report a new case of pellagra in a 29-year-old woman in whom the diagnosis of megaduodenum was made. Megaduodenum is a rare condition that can be idiopathic or secondary to visceral myopathy or neuropathy. Parenteral supplementation with niacin has resulted in a quick response of dermatological and psychiatric symptoms. To our knowledge, no case of pellagra due to megaduodenum has been reported in literature.

Background: Malabsorptive surgical procedures lead to deficiencies in fat-soluble vitamins. However, results concerning serum vitamin D (25OHD) after gastric bypass (GBP) are controversial. The aim of the study was to assess the influence of GBP on 25OHD and calcium metabolism., Methods: Parameters of calcium metabolism were evaluated in 202 obese subjects before and 6 months after GBP. Thirty of them were matched for age, gender, weight, skin color, and season with 30 subjects who underwent sleeve gastrectomy (SG). A multivitamin preparation that provides 200 to 500 IU vitamin D3 per day was systematically prescribed after surgery., Results: In the 202 patients after GBP, serum 25OHD significantly increased from 13.4 ± 9.1 to 22.8 ± 11.3 ng/ml (p < 0.0001), whereas parathyroid hormone (PTH) did not change. Despite a decrease in calcium intake (p < 0.0001) and urinary calcium/creatinine ratio (p = 0.015), serum calcium increased after GBP (p < 0.0001). Preoperatively, 91 % of patients had 25OHD insufficiency (< 30 ng/ml), 80% deficiency (< 20 ng/ml), and 19% secondary hyperparathyroidism (> 65 pg/ml) vs. 76, 44, and 17%, respectively, following GBP. Serum 25OHD was negatively correlated with BMI at 6 months after GBP (R = -0.299, p < 0.0001). In the two groups of 30 subjects, serum 25OHD and PTH did not differ at 6 months after GBP or SG., Conclusions: At 6 months after GBP, serum 25OHD significantly increased in subjects supplemented with multivitamins containing low doses of vitamin D. These data suggest that weight loss at 6 months after surgery has a greater influence on vitamin D status than malabsorption induced by GBP.

We report the case of a patient presenting with L-thyroxine pseudomalabsorbtion, a figure in which patients are in a state of biological, and, frequently, clinical hypothyroidism secondary to a lack of adherence to substitutive thyroid treatment. We then review the different causes of true thyroid hormones malabsorption and the different approaches to these situations. We also suggest diagnostic and therapeutic attitudes for clinicians facing suspicious cases of hormone malabsorption.

This study aims to describe the clinical consequences of vitamin A deficiency (VAD) in pregnant women after bariatric surgery. Included are studies on VAD during pregnancy and after bariatric surgery conducted in humans from 1993 to 2011. There are few investigations on the relationship between pregnancy and bariatric surgery and on the damage to the binomial mother-child resulting from VAD in this relationship. The high percentage of VAD in the postoperative period is a cause for concern, especially considering the function of this vitamin in certain biological moments and in moments of intense nutritional demand. This vitamin serum evaluation is recommended during the prenatal period.