Endocrine Abstracts

Introduction: NICE recommends weight loss surgery as a treatment option for people with obesity. However, long term data on outcomes and complications on surgery are limited. We report unexplained adrenal insufficiency post bariatric surgery.

Case report: Patient one

27 years old lady underwent Roux-en-Y gastric bypass (RYGB). Weight loss (kg) was from 130.2 to 73.2 over a 2-year period. Patient complained of general unwell and dizziness. No orthostatic hypotension was noted. Random cortisol (nmol/l) was low at 98 and Short synacthen test (SST) showed 0 and 30 min Cortisol of 158 and 386 respectively with a low ACTH.

Patient two

46 years old man underwent RYGB. Weight loss was from 151.8 to 56.8 over a period of 18 months. He complained of episodes of vomiting, sweating and black outs with no postural hypotension. Random cortisol was 50 and SST demonstrated cortisol of 108 and 281 at 0 and 30 min respectively. Steroid replacements were commenced and he improved symptomatically.

Discussion: The cause of adrenal insufficiency in the above cases remains unexplained. Adrenal insufficiency has been reported after major surgery as result of stress or blood loss affecting the pituitary gland. However only one case has been reported post bariatric surgery. Possible mechanisms are malabsorption of bile affecting cholesterol leading to reduced precursor for steroid synthesis, malabsorption of trace elements and vitamins (especially selenium and vitamin B5) that are steroid biosynthesis cofactors, re-setting of hypothalamo-pituitary–adrenal axis due to weight loss as in anorexia nervosa and perioperative complications such as blood loss causing pituitary/adrenal infarct or apoplexy.

Conclusion: These two cases suggest the importance of patient selection, pre surgical counselling and long term follow-up post bariatric surgery.