Severe Malnutrition and Celiac Disease Following Gastric by-Pass Surgery - (2023)

Severe Malnutrition and Celiac Disease Following Gastric by-Pass Surgery - (1)

Juan Manuel Marini1, Eduardo Coghlan2, Luis Laferrere3, María Elisa Zenon4, Alberto San Roman5 and Angel Nadales6

1,2,3,4,6 Department of Gastroenterology, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina

5Department Pathology, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina

Volume 2014 (2014,Article ID 130992,International Journal of Case Reports in Medicine,5 pages,DOI: 10.5171/2014.130992

Received date : 17 February 2014;Accepted date : 8 June 2014;Published date : 19 September 2014

Academic editor:Fritz Friedrich Horber

Cite this Article as:Juan Manuel Marini, Eduardo Coghlan, Luis Laferrere, María Elisa Zenon, Alberto San Roman and Angel Nadales (2014),"Severe malnutrition and celiac disease following gastric by-pass surgery ", International Journal of Case Reports in Medicine, Vol. 2014 (2014), Article ID 130992, DOI: 10.5171/2014.130992

Copyright © 2014. Juan Manuel Marini, Eduardo Coghlan, Luis Laferrere, María Elisa Zenon, Alberto San Roman and Angel Nadales . Distributed under Creative Commons CC-BY 3.0


A thirty seven year old female patient developed severe postprandial pain, chronic diarrhea and clinical and biochemical malabsorption syndrome twelve months after gastric by-pass surgery. Vascular and infectious diseases were ruled out during clinical workup and the diagnosis of celiac disease was reached using antibody testing and endoscopic biopsies. Clinical manifestations disappeared within two weeks of strict gluten-free diet.

Keywords:Celiac disease, bariatric surgery, obesity, gastric by-pass surgery and malabsorption.


Recent studies report that 13% of celiac disease (CD) patients have a body mass index (BMI) of 30 or above [4]. Celiac disease is a rare but potentially fatal cause of severe malnutrition in patients undergoing bariatric surgery. A preoperatory diagnosis could change the treatment strategy or surgical technique.

Materials and Methods

In June 2011, a thirty six year old female patient with class III obesity (BMI: 48,4 kg/m2) and a normal pre-surgical esophagogastroduodenoscopy (EGD) underwent gastric by-pass surgery. Four months after surgery, in spite of continuous treatment with poli-vitamins, iron supplements and adequate compliance to the diet, the patient referred significant hair loss.

A year later, she developed severe post-prandial pain, nausea, vomiting, chronic diarrhea with 5 to 10 liquid bowel movements per day, nocturnal diarrhea, and asthenia. She had lost 70 kg in 14 months reaching a BMI of 21 kg/m2. The patient was admitted at our institution afebrile with normal blood pressure and heart rate.


Initial laboratory results showed WBC 6,06 x109/L, Hemoglobin 6,51 mmol/L, Platelets 191 x10 9/L, Glucose 4,11 mmol/L, Urea 8,92 mmol/L, Total Cholesterol 2,09 mmol/L, Creatinine 48,62 μmol/L, ALT 58 U/L, AST 111 U/L, Albumin 1,7 gr/dL, Na 139 mmol/L, K 4,2 mmol/L, Prothrombin 64%, TSH 3,48 mlU/ml and cholecalciferol and vitamin B12 deficit. Parasitologic fecal test, fecal leukocytes and cultures were negative but stool steatocrit was 6,6% (< 4%).

The patient received empirical treatment for bacterial overgrowth with antibiotics, probiotics, bismuth subsalicylate and loperamide without response. Abdominal Doppler ultrasound for vascular lesions was normal and CT scan with mesenteric angiotomography informed anatomical findings according to surgical records with mild ascites and mucosal edema.

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An EGD was performed with findings according to surgical history; gastric remnant, gastrojejunal anastomosis and alimentary limb presented no evident lesions. Biopsies from jejunal folds informed increased intraepithelial lymphocytes, mucosal atrophy with moderate villous atrophy and crypt hyperplasia. (FIGURE 1 and FIGURE 2)

Five days later, the following results were received: Total IgA: 340 mg/dL, anti transglutaminase IgA: 117,2 U/ml (<30), antiendomise IgA: positive.


As soon as the diagnosis of CD was made, the patient was started on gluten-free enteral nutrition due to gastric intolerance and three days later oral intake was resumed. All clinical symptoms were resolved and the patient was discharged on the seventh day.

Outcome and Follow-up

The patient remained symptom free and regained 4,6 kg thirty days after discharge.


CD is a systemic immune-mediated disorder triggered by dietary gluten in genetically susceptible persons. CD affects 0.6 to 1.0% of the population worldwide [1,2,3] and has classically been related to malabsorption and weight loss. Recent studies show that the majority of CD sufferers do not display classic symptoms and are more likely to be overweight or obese than underweight at the time of presentation.[4,5]

Obesity is a chronic disease that is increasing in prevalence in the United States and worldwide. In general, greater body mass index (BMI) is associated with increased rate of death from all causes and from cardiovascular disease. Estimates for the annual number of excess deaths attributable to obesity in the United States are variable and range from 111,909 to 365,000 [6] Dickey and col. (2006) [5] and Tucker and col. (2012) [4] report a median BMI of 24,6 and 23,6 kg/m2 with 39% and 31% of overweight, and 13% of obesity in both populations at the initial assessment of CD patients. Prevalence of obesity was higher in women. They also noted that the percentage of patients who are overweight or obese at first referral increased every year.

Furse and Mee (2005) [7] describe atypical presentations of CD in four obese women with a BMI over 40 kg/m2. Semenaro (1986) [8] postulates that obese CD patients are probably able to compensate for proximal malabsorption by using intact absorptive mechanisms more distally. Fat absorption remains static and so do the ability to maintain energy intake, and as the surface area of the small bowel increases with age, children develop the ability to ingest adequate compensatory energy. Those whose energy intake is excessive will become obese.

Cuenca-Abente and col. (2012) report five patients being diagnosed with CD based on endoscopic findings during pre-surgical evaluation for bariatric surgery [9] and bibliographic investigation offered three cases where the diagnosis of CD was performed after a jejunoileal by-pass [10,11,12], one of them with fatal outcome due to hepatorenal failure.


The case we present shows the development of CD with severe malnutrition and clinical deterioration in a patient who had undergone recent gastric by-pass surgery. After jejunal by-pass surgery, adaptation of the small intestine occurs over a period of months and is evidenced by ileal villi hypertrophy. CD may interfere with this adaptation and exacerbate malabsorption leading to malnutrition. CD alters natural absorptive mechanisms and any surgical procedure affecting or interfering with absorption should be avoided.

Should a similar clinical scenario be presented, with the diagnosis of CD after a gastric by-pass surgery, it is imperative to start adequate nutritional support with gluten free diet and reposition of minerals and vitamins. Although the literature is scarce, if the patient remains unresponsive, steroid treatment could be an option (1) and one could consider a return to normal anatomy surgery or a reverse jejunoileal by-pass surgery as last resource alternatives (10).

Italian physicians De´ Angelis, Carra and Vincenzi (2012) propose serologic screening test for patients undergoing bariatric surgery [11] based on the excellent sensitivity (94%) and specificity (97%) of serum IgA antitransglutaminase antibodies [1-3, 11]. Cuenca-Abente and col. (2012) recommend only a careful evaluation of the duodenum, serological test and biopsies on those patients with abnormal endoscopic appearance. [9] The latter group prefers sleeve gastrectomy over gastric by-pass in obese patients with CD. Three patients were operated after being placed on a gluten free diet. None developed complications or classic symptoms of CD, serological marker levels normalized and all three achieved standard weight loss on follow-up.

In conclusion, obesity is a pandemic disease and CD is a condition that can affect morbidly obese patients. Serological screening test for patients enrolling a bariatric surgery program could be beneficial because a preoperatory diagnosis could help make better decisions both in the treatment strategy and surgical technique.

Figure 1 and 2: Biopsies from jejunal folds (HE stain, x10 and x40): Increased intraepithelial lymphocytes, mucosal atrophy with moderate villous atrophy and crypt hyperplasia.

No funding was received

We manifest no conflict of interest

Ethics: The patient has given her informed consent and the study protocol has been approved by the Hospital´s Ethics committee.


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Can gastric bypass surgery cause celiac disease? ›

Celiac disease may as a consequence of surgery, including weight-loss surgery. According to Mayo Clinic, while the exact cause is unknown, it is suspected that the trauma caused by surgery may lead to the body having an abnormal immune response to eating gluten.

What causes malnutrition after gastric bypass? ›

Bypass of the duodenum impairs mixing of ingested nutrients with bile acids and pancreatic enzymes leading to maldigestion. The combination of malabsorption and maldigestion, while resulting in significant weight loss, predisposes to malnutrition.

What is the most frequent cause of death after bariatric surgery? ›

Leaks. An anastomotic leak is the most dreaded complication of any bariatric procedure because it increases overall morbidity to 61% and mortality to 15%.

What are 3 common long term complications of gastric bypass? ›

Longer term risks and complications of gastric bypass can include: Bowel obstruction. Dumping syndrome, causing diarrhea, nausea or vomiting.
  • Excessive bleeding.
  • Infection.
  • Adverse reactions to anesthesia.
  • Blood clots.
  • Lung or breathing problems.
  • Leaks in your gastrointestinal system.
25 Jun 2022

Can you develop gluten intolerance after gastric bypass? ›

Many weight-loss patients, who have had Roux en Y gastric bypass surgery or other bariatric procedures, like gastric sleeve lap band and other surgeries performed by bariatric doctors in Dallas, Texas develop gluten intolerance. It can cause diarrhea, weight loss and nutritional difficulties.

Can gastric bypass cause autoimmune diseases? ›

Conclusions. Patients undergoing bariatric surgery show immunological changes which might eventually lead to develop an autoimmune disease.

Does weight loss surgery cause malnutrition? ›

Types of malnutrition after bariatric surgery include protein-energy malnutrition and deficiencies of micronutrients, such as iron, folate, vitamin A, and vitamin B12. Bariatric patients who do not adhere to the recommended dietary guidelines are at a greater risk of developing relevant malnutrition [13].

What is Candy Cane syndrome? ›

Candy cane syndrome is a rare complication reported in bariatric patients following Roux-en-Y gastric bypass. It occurs when there is an excessive length of roux limb proximal to gastrojejunostomy, creating the possibility for food particles to lodge and remain in the blind redundant limb.

What is the life expectancy after gastric bypass? ›

The adjusted median life expectancy in the surgery group was 3.0 years (95% CI, 1.8 to 4.2) longer than in the control group but 5.5 years shorter than in the general population. The 90-day postoperative mortality was 0.2%, and 2.9% of the patients in the surgery group underwent repeat surgery.

Can a gastric bypass cause problems years later? ›

Long-term complications may include ulcers, scarring, and narrowing of the anastomosis (where the intestine is connected to the gastric pouch), known as a stricture. A drainage tract through the skin called a fistula may also develop. A fistula could develop between the gastric pouch and the bypassed stomach.

What are long term complications after bariatric surgery? ›

Bariatric Surgery Long-Term Risks

Dumping syndrome, a condition that can lead to symptoms like nausea and dizziness. Low blood sugar. Malnutrition. Vomiting.

What percentage of people have complications after gastric bypass surgery? ›

Ten percent to 20 percent of patients who have weight-loss operations require follow-up operations to correct complications. Abdominal hernias are the most common complications requiring follow-up surgery.

What happens if you don't get enough protein after bariatric surgery? ›

The Importance of Protein

If your diet doesn't include enough protein, you might notice thinning hair about 6 months to a year after weight loss surgery. That's because the human body can't make protein without food – and also has no way to store protein – making it important to consume enough daily.

Is malabsorption permanent after gastric bypass? ›

The food will eventually pass from the upper stomach to lower stomach, and from there will pass through the normal digestive tract. Henceforth, there is no malabsorption effect. The adjustable band (LAGB) can be tightened according to the patient's appetite and feeling of satiety with small portions.

How do you prevent malabsorption after gastric bypass? ›

The American Society for Metabolic and Bariatric Surgery recommends that you start taking vitamin A, D, and K supplements about 2 to 4 weeks after BPD-DS surgery. This will help prevent nutritional deficiencies. You may also need calcium, iron, B-complex, and multivitamins.

Can bariatric surgery cause food intolerances? ›

After gastric band surgery, you won't eat as much as you used to. But the surgery may lead to a number of side effects, including food intolerance. Food intolerance means that your body can't digest certain foods the way it should. You may have unpleasant symptoms, such as nausea and vomiting.

Is there surgery for celiac disease? ›

Overview. Surgery is not the first line treatment option for patients with celiac disease. Surgery is usually reserved for patients with refractory or pre-malignant complications, such as Enteropathy Associated T-cell Lymphoma (EATL) and ulcerative jejunitis (UJ).

What foods can I eat that are gluten-free? ›

Gluten-free flours — rice, soy, corn, potato and bean flours. Hominy (corn) Millet. Quinoa.
Many naturally gluten-free foods can be a part of a healthy diet:
  • Fruits and vegetables.
  • Beans, seeds, legumes and nuts in their natural, unprocessed forms.
  • Eggs.
  • Lean, nonprocessed meats, fish and poultry.
  • Most low-fat dairy products.

Can gastric bypass cause Crohn's disease? ›

Several nutritional and gastrointestinal complications after bariatric surgery have been described during the last 10 years. The authors present two patients with diarrhoea and malnutrition; one after RYGBP and the other after jejunoileal bypass surgery. These patients were subsequently diagnosed with Crohn's disease.

Why do my bones hurt after gastric bypass? ›

Your Bones and Joints Are Adjusting to Weight Loss

As you lose weight, your bones and joints may not be used to the change in weight. Combine this with potential core strength issues and you have a recipe for temporary joint discomfort. This is especially noticeable around the knees, hips, and lower back.

Can surgery trigger an autoimmune disorder? ›

Autoimmune disorders occur when the body attacks its own tissues. "Substantial evidence has already been found to support an autoimmune cause of [Guillain-Barre syndrome]," Hocker said. "Perhaps the surgical procedure itself and the stress of anesthesia triggered an autoimmune reaction in those who were predisposed."

What is secondary malnutrition? ›

Secondary malnutrition arises when an individual's dietary intake is sufficient, but energy is not adequately absorbed by the body as a result of infectious conditions such as diarrhoea, measles or parasitic infections, or medical or surgical problems affecting the digestive system.

Do you absorb nutrients after gastric bypass? ›

After gastric bypass surgery, your body will not absorb some important vitamins and minerals. You will need to take these vitamins and minerals for the rest of your life: Multivitamin with iron.

Can you lose too much weight after gastric bypass? ›

Studies show that on average sleeve gastrectomy patients lose 70% of their excess weight. Some lose more and some lose less. No one, however, loses too much weight to the point of becoming malnourished.

Can you become anorexic after gastric bypass? ›

Some patients developed an eating disorder after surgery. Others had a pre-existing eating disorder that worsened after gastric bypass. Anorexia nervosa, bulimia and binge eating disorder are serious conditions that interfere with both physical and psychological health and quality of life.

What vitamins do you need after gastric bypass? ›

Gastric Bypass: Doctors recommend that gastric bypass surgery patients take a complete multivitamin, calcium with Vitamin D, iron and Vitamin C, Vitamin D, and Vitamin B12.

Can you have bariatric surgery twice? ›

In some cases, a second surgery to repair — or redo — a gastric bypass may be appropriate. This is especially true if the anatomy of your stomach and small intestine have changed, such as with a fistula (additional connection between the stomach and intestine).

What percent of gastric bypass patients gain the weight back? ›

Many people do indeed find success with gastric bypass in the short term, but a majority of participants unfortunately regain much of the weight they lost. In fact, one study indicated that 59% of people regained 20% or more of the weight they originally lost after surgery.

What is the best weight-loss surgery 2022? ›

Gastric bypass has been the gold standard and maybe still is, but sleeve gastrectomy, being a simpler operation with almost as good results—for weight loss, anyway—has supplanted it. I'd say 60 to 70 percent of our primary operations are sleeves.

When does bariatric surgery not work? ›

Failure after bariatric surgery is defined as achieving or maintaining less than 50% of excess weight loss (EWL) over 18 to 24 months or a body mass index (BMI) of greater than 35. The failure rate of LRYGB has been reported to be ∼15% with a long-term failure rate of 20–35% and a revision rate of 4.5%.

Can Coeliacs be obese? ›

It's Possible to Be Overweight With Celiac Disease

For example, in a 2010 study published in the Journal of Clinical Gastroenterology, 15.2% of adults with celiac disease were overweight when they were diagnosed and 6.8% were obese. 3 Together, these outnumbered the 17.3% who were underweight.

What foods can I eat that are gluten-free? ›

Gluten-free flours — rice, soy, corn, potato and bean flours. Hominy (corn) Millet. Quinoa.
Many naturally gluten-free foods can be a part of a healthy diet:
  • Fruits and vegetables.
  • Beans, seeds, legumes and nuts in their natural, unprocessed forms.
  • Eggs.
  • Lean, nonprocessed meats, fish and poultry.
  • Most low-fat dairy products.

What is celiac belly? ›

Symptoms of celiac disease include: Gas, a swollen belly, and bloating. This happens because the small intestine can't absorb nutrients from food. You may also have mild stomach pain, but it usually isn't severe.

Can stress make celiac worse? ›

Sometimes celiac disease becomes active after surgery, pregnancy, childbirth, viral infection or severe emotional stress.

Why do some celiacs gain weight? ›

People with celiac disease may experience weight gain after starting a gluten-free diet; this initial weight gain indicates that their intestinal health is improving and they are more effectively absorbing nutrients. However, gaining too much weight can lead to multiple health problems.

What can I eat for breakfast gluten-free? ›

Gluten-free Meal Ideas - Breakfast
  • Rice Chex or Corn Chex or other gluten-free cereal with milk, nut milks, fresh fruit.
  • Corn tortillas, warmed with scrambled eggs, chopped tomato, and melted cheese.
  • Cream of rice cereal with chopped almonds and milk.
  • Gluten-free waffles with butter and syrup.

Do potato chips have gluten? ›

Most potato chips, veggie chips, and tortilla chips are gluten-free, though you may want to look for a gluten-free label just to be safe. Meanwhile, you should avoid pita chips and any chips made with flour, whole wheat, wheat starch, or malt vinegar.

Does pasta have gluten? ›

All wheat pasta contains gluten, including spaghetti, fettuccine, macaroni, lasagne, and ravioli. Not all breakfast cereals contain wheat, but many do, so be sure to check the nutrition labels. Also, be aware that oats are often raised and processed with wheat.


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