A Case of Profound Malabsorption and Vision Changes From Complications of a Biliopancreatic Diversion With Duodenal Switch

Introduction: The biliopancreatic diversion with duodenal switch procedure involves a partial sleeve gastrectomy with preservation of the pylorus and creation of a Roux limb with a short common channel. We present an interesting case of severe malabsorption causing blurry vision and color blindness. Case Description/Methods: A 52-year-old female with history of stage 1 ovarian cancer treated surgically 3 years prior with no evidence of active malignancy as well as a history of a biliopancreatic diversion with duodenal switch 20 years prior to presentation was admitted with hypo-albumemia to 1.7 g/dl and blurry vision with color blindness. For recent onset of lower extremity edema, she had undergone computed tomography (CT) of abdomen/pelvis, cardiac stress test, echocardiogram, and lower extremity ultrasounds prior to admission which were unremarkable. Urine was bland for protein loss. Serum studies, which included erythrocyte sedimentation rate, C-reactive protein, and celiac serologies, were negative. Gastrointestinal infectious assays and stool analysis for ova and parasites were negative. Stool alpha-1 antitrypsin and methyl malonic acid were in normal limits. Her extensive work-up revealed profound mineral and fat-soluble vitamin deficiencies, as outlined in Table 1. She underwent computed enterography which showed minimal pan colonic thickening - possibly a nonspecific mild colitis. Subsequent upper endoscopy and colonoscopy with random biopsies were normal, other than mild mucosal edema. A comprehensive ophthalmic evaluation showed no evidence of retinal pathology, optic neuropathy, changes in color vision were due to severe Vitamin A deficiency. Given no alternative etiology was found, the patient’s symptoms were attributed to malabsorption secondary to biliopancreatic diversion with duodenal switch. The patient was started on total parental nutrition (TPN) and maintained on high doses of Vitamin A 10000 units daily, Vitamin D 50.000 units daily, and Vitamin E 400 units daily. Her anasarca has resolved since TPN initiation, and there has been significant improvement in her albumin level (3.9 g/dl) and vitamin levels. Her vision continues to be blurry despite being on TPN and supplementation. She is currently being evaluated for revision of her prior surgery. Discussion: The biliopancreatic diversion with duodenal switch has significant risks of long-term malabsorption, thus familiarity with this procedure and the potential complications is critical to identify and treat impacted patients effectively.Table 1.: Mineral and Fat-Soluble Vitamin Deficiencies.