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Progressive Confusion and Recurrent Falls After Bariatric Surgery

  • AUTHORS:
    Christopher J. Lundberg, DO1 • Daniel Tran, DO2 • Alan Lucerna, DO3 • James Espinosa, MD3 • Eric Maddock, DO3 • Robin J. Lahr, DO3

    AFFILIATIONS:
    1Department of Emergency Medicine, FirstHealth of the Carolinas, Pinehurst, NC
    2Department of Cardiology, Rowan University School of Osteopathic Medicine, Stratford/Jefferson Health New Jersey, Stratford, NJ
    3Department of Emergency Medicine, Jefferson Health New Jersey, Stratford, NJ

    CITATION:
    Lundberg CJ, Tran D, Lucerna A, Espinosa J, Maddock E, Lahr RJ. Progressive confusion and recurrent falls after bariatric surgery. Consultant. Published online May 23, 2022. doi:10.25270/con.2022.02.00011

    Received September 11, 2021; accepted October 20, 2021.

    DISCLOSURES:
    The authors report no relevant financial relationships.

    CORRESPONDENCE:
    Alan Lucerna, DO, Department of Emergency Medicine, Jefferson Health New Jersey, 18 East Laurel Road, Stratford, NJ 08084 (Alan.Lucerna@jefferson.edu)


    A 26-year-old woman presented to the emergency department (ED) with progressive confusion and recurrent falls. The patient reported having vomiting and diarrhea for 1 week and several falls 1 day before her ED visit. She had an uncomplicated laparoscopic Roux-en-Y gastric bypass procedure 4 months prior. The patient denied history of alcohol consumption.

    Physical examination
    Clinical examination revealed the patient was somewhat combative and somnolent, with a Glasgow Coma Score of 13 and an ataxic gait. Upon cranial nerve examination, the patient demonstrated mild restrictive eye movements without conjugate disturbance.

    Diagnostic testing
    Routine laboratory testing showed an anion-gapped metabolic acidosis. Toxicity workup for acetaminophen, salicylate, and alcohol was negative; a volatile alcohol panel was also negative. Serum osmolality and ammonia levels were within normal limits. Liver function testing showed transaminitis, with an ALT level of 518 U/L and AST level of 233 U/L. A noncontrast computed tomography (CT) scan of the head was unremarkable. A subsequent lumbar puncture showed no evidence of meningitis. The patient was subsequently admitted to the hospital with neurology consultation.

    What is the most likely diagnosis?

    A. Bacterial meningitis

    B. Alcohol withdrawal

    C. Wernicke encephalopathy

    D. Dehydration

    E. Acute viral hepatitis

References

1. Osiezagha K, Ali S, Freeman C, et al. Thiamine deficiency and delirium. Innov Clin Neurosci. 2013;10(4):26-32.

2. Şimşek T, Şimşek HU, Cantürk NZ. Response to trauma and metabolic changes: post-traumatic metabolism. Ulus Cerrahi Derg. 2014;30(3):153-159. doi:10.5152/UCD.2014.2653

3. Santos Andrade C, Tavares Lucato L, da Graca Morais Martin M, et al. Br J Radiol. 2010;83(989):437-446. doi:10.1259/bjr/27226205

4. Lyons DA, Linscott LL, Krueger DA. Non-alcoholic Wernicke encephalopathy. Pediatr Neurol. 2016;56:94-95. doi:10.1016/j.pediatrneurol.2015.12.007

5. Busani S, Bonvecchio C, Gaspari A, et al. Wernicke’s encephalopathy in a malnourished surgical patient: a difficult diagnosis. BMC Res Notes. 2014;7:718. doi:10.1186/1756-0500-7-718

6. Oudman E, Wijnia JW, van Dam M, Biter LU, Postma A. Preventing Wernicke encephalopathy after bariatric surgery. Obes Surg. 2018;28(7):2060-2068. doi:10.1007/s11695-018-3262-4

7. Aasheim ET. Wernicke encephalopathy after bariatric surgery: a systematic review. Ann Surg. 2008;248(5):714-720. doi:10.1097/SLA.0b013e3181884308

8. DeMaria E, Trigilio-Black C. Alarming increase in malpractice claims related to Wernicke’s encephalopathy post bariatric surgery: an alert to monitor for thiamine deficiency. Bariatric Times. 2018;15(7):8-9.

9. Dung D, Chien K, Ma L. Case report: Wernicke encephalopathy following Roux-en-Y gastric bypass. Am Fam Physician. 2020;102(4):197-198.

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