Endocrine Abstracts

Introduction: Wernicke’s encephalopathy, resulting from thiamine deficiency, is a rare but serious neurological complication of bariatric procedures. The diagnosis is still difficult since the classic clinical triad (confusion, ataxia and oculomotor abnormalities) and the typical radiological features (areas of hyperintensity in mammillary bodies, thalamus, periaqueductal and periventricular gray matter) are not always present. Also, thiamine blood tests are not broadly available to confirm the diagnosis. Only a few cases of Wernicke’s encephalopathy after sleeve gastrectomy have been reported in literature, nonetheless subjects can be underdiagnosed and their cases underreported.

Case presentation: We present the case of a 20-year-old female patient who developed Wernicke’s encephalopathy after sleeve gastrectomy for grade II obesity (BMI 36.3 kg/m2) with metabolic complications (dyslipidemia, nonalcoholic fatty liver disease). She presented to the Emergency Department two months after surgery showing confusion, gait ataxia and horizontal nystagmus. Persistent vomiting and lack of compliance to vitamin intake were reported. She had already lost 19 kg, from 105 to 86 kg (BMI 29.8 kg/m2). Cerebral MRI showed acute bilateral lesions in periaqueductal and periventricular regions. After excluding chronic alcohol use, a diagnosis of Wernicke’s encephalopathy was made. Unfortunately, thiamine dosage was not available. Parenteral thiamine supplementation was immediately administered (500 mg IV every 8 hours for 10 days), obtaining a progressive resolution of altered mental status, motor ataxia and nystagmus. On the contrary, anterograde, retrograde and working memory impairment persisted, as confirmed by cognitive tests. She was discharged with oral thiamine supplementation (300 mg daily) and underwent long-term physical, cognitive and psychological rehabilitation. After a 2-years follow up, she is compliant to a balanced fractionated diet and vitamin supplementation. Her body weight progressively reduced to 65 kg (BMI 22.5 kg/m2) and no other nutritional deficiencies developed. A new cerebral MRI showed regression of the neuroradiological findings. However, a minimal memory impairment remained.

Conclusion: Wernicke’s encephalopathy is a concrete possibility after sleeve gastrectomy and should always be suspected in patients with recurrent vomiting, poor nutritional intake and non-compliance to vitamin supplementation. Immediate and aggressive thiamine supplementation is mandatory to prevent patients from irreversible neurological impairment, even though full recovery is not always achieved. A multidisciplinary approach (surgeon, endocrinologist, neurologist, dietitian, psychologist, physiotherapist) is required for the long-term management of these patients.