Endocrine Abstracts

Introduction: Bariatric surgery is now a common surgical procedure for weight management recommended by NICE. Complications such as dumping syndrome, micronutrient deficiencies are well documented in the literature. Here we discuss a lesser reported complication of adrenal insufficiency and its management in five patients following gastric bypass surgery.

Case reports: All patients presented with one or more of the following symptoms: sweating, anxiety, weight regain, hypoglycaemia, collapse with transient loss of consciousness and profound weight loss.

Baseline cortisol and cortisol response following a challenge with synacthen were all suboptimal. All patients had normal pituitary function and imaging, adrenal antibody was negative. Patients were commenced on oral hydrocortisone with resulting improvement in only three of them.

Discussion: The cause of adrenal insufficiency in the above cases remains unexplained. 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 or reduction in steroid metabolites produced by adipose tissue. Rapid weight loss, which is expected with bariatric surgery, may mask symptoms of adrenal insufficiency.

Patients who did not have an improvement in symptoms had abnormal cortisol day curve, which was due to malabsorption of oral hydrocortisone. Parental hydrocortisone resulted in improvement of symptoms but resulted in significant weight gain. One of these patients had been commenced on a subcutaneous hydrocortisone pump with significantly reduced dose of hydrocortisone and improvement in symptoms.

Conclusion: These cases highlight the importance of long-term follow-up of patient’s post-bariatric surgery and bariatric team needs to consider the possibility of adrenal insufficiency, when patient’s presents with unexplained symptoms.