Download Philippine Society of Endocrinology and Metabolism And Makati

Philippine Society of
Endocrinology and Metabolism
And
Makati Medical Center
Section of Endocrinology, Diabetes and
Metabolism
58th Inter-Hospital Grand Rounds
Jowett Jardine M. Golangco, MD and Eddelyn G. Salomon, MD
Objectives:
1. to present the case of an obese,
diabetic undergoing bariatric surgery
2. to understand the pathophysiology of
obesity and its
complications/consequences
3. to discuss the advantages and
disadvantages of bariatric surgery in a
diabetic patient
4. to discuss the nutrition preparation
pre- and post-operatively in a diabetic
patient undergoing bariatric surgery
Synopsis
We present the case of an obese, diabetic male
who will undergo bariatric surgery, a case which is now
becoming a common scenario in the clinics with the
increasing prevalence of obesity. Concomitant with this
is the development of the complications of obesity such
as diabetes, dyslipidemia, hypertension and obstructive
sleep apnea.
To date, bariatric surgery is the only effective
means to address morbid obesity. We now give
attention on weighing the issues on bariatric surgery in
diabetic patients.
History of the Present Illness:
This is the case of a 52 year-old Filipino male referred to our Weight Wellness Center.
Thirty years ago, he was apparently well and was weighing about 132 – 150 pounds.
Twenty years ago, he went to the United States for a study grant. Food was cheap and very accessible.
Coming from an impoverished family in the Philippines and taught to eat everything in his plate, this provided him the
absolute freedom to consume food. He enjoyed eating. He smoked cigarette and drank alcohol more frequently. He
would have three or more meals a day consisting of restaurant food or food from a fastfood chain (McDonald’s, KFC).
His diet included steak, chicken wings and bacon. On rare occasions, he would have home-cooked food which was
usually deep-fried meat served with potatoes and microwavable packed vegetables. His activity then included few
sessions of basketball lasting for 15-30 minutes and swimming, once every 2 weeks. His weight started to rise to 175
to 200 pounds.
Ten years ago, already back home in the Philippines working as a vice-president in a business development
firm in the morning and doing teaching job at night, his eating habits were no better than when he was in the United
States. Stress of his work also fuelled his eating habits. It was also at that time that he met an old-time Chinese friend
who also enjoyed food. They would frequently go to eat-all-you-can restaurants. They both loved to eat Peking duck,
lechon de leche and crispy pata consuming a kilo or more of these together. Restaurant-dining then became a hobby.
His smoking and alcohol-drinking also continued. His weight steadily increased to about 220 pounds. Towards the
end of that decade, after an annual medical examination, he was already diagnosed to have hypertension, diabetes and
dyslipidemia. He started to see an endocrinologist. He was prescribed Gliclazide, Metformin and Fenofibrate and
advised to go on a diet. At this time, he started to take Bangkok pills and Kankunis tea intermittently for 3 to 6 months
in an effort to lose weight. However, instead of losing weight, he gained more as he ate more because he thought this
would compensate for the more frequent episodes of bowel movement. Failure in losing weight and the expense of the
above regimen made him to discontinue them.
Seven years ago, his wife complained that he was snoring heavily. He would wake up feeling tired and
complained of headache. Consultation was made with a pulmonologist who diagnosed him to have Obstructive Sleep
Apnea. CPAP was advised but was not started. He also sought consult with another endocrinologist. He was started
on Orlistat and was prescribed a computed diet. However, the prescribed diet was not followed as he continued buffet
dining. He weighed between 230 to 240 pounds.
Six years ago, he was started on insulin therapy due to uncontrolled diabetes. Orlistat was continued. At this
time he was found to have grade 1 Hypertensive retinopathy and arteriosclerosis. His weight continued to increase to
about 230 to 260 pounds.
Four years ago, he started to complain of shortness of breath and easy fatigability. He was panting just
climbing a flight of stairs. Consultation with another pulmonologist was made who diagnosed him to have severe
Obstructive Sleep Apnea. He was again advised to start CPAP which he followed. He also consulted a cardiologist. A
coronary angiography was done which revealed 3-vessel disease with about 60% stenosis. He was also seen by a
nephrologist due to increasing creatinine levels. Metformin was stopped. He decided to stop drinking alcohol and quit
smoking. However, with smoking cessation, he ate more often to suppress his craving for cigarettes. He weighed
between 250 to 260 pounds. Orlistat was subsequently discontinued.
Three years ago, he enrolled in a fitness gym (Fitness First) and Zunic therapy for 2-3 months. This was
followed by a cardiac rehabilitation program which he underwent intermittently for 2-3 months. He started on South
Beach diet. He lost weight of about 20 pounds. However, due to conflicts with his work schedule he stopped
undergoing the programs, and regained back and more of his previous weight. He weighed almost 270 pounds
One year ago, he was prescribed Sibutramine and took the medication as prescribed. Contrary to its
indication, he gained weight. With his increasing creatinine levels and failure of the medication, this was stopped after
6 months. He was advised to have intragastric-balloon; however, due to financial constraints this was not done.
Six months ago, due to uncontrolled diabetes requiring 110 units of insulin per day, he was advised to undergo
bariatric surgery. In preparation for the procedure, he was referred to the following services for clearance: cardiology,
pulmonology and psychiatry.
Upon admission, he weighed 275 pounds.
Past Medical History
He was diagnosed to have diabetes mellitus type 2, dyslipidemia and hypertensive atherosclerotic coronary
artery disease ten years ago. Three years PTA, he underwent coronary angiography in 2006 which revealed 3-vessel
disease.
Four years PTA, he was diagnosed to have severe Obstructive Sleep Apnea and is currently on CPAP. Three
years PTA, he was diagnosed to have Chronic Kidney Disease probably secondary to diabetic nephropathy vs
hypertensive nephrosclerosis. He has Benign Prostatic Hypertrophy and Bronchial Asthma.
He has no previous surgeries and has no allergies to food or medications.
Family History
He is the 3rd among 6 children. Both his parents were apparently of normal weight. He had two siblings who
were normal weight, two siblings who were overweight and another sibling who is underweight.
He has family history of diabetes mellitus type 2 (mother).
Social and Environmental History
He works as a professor in a university. He is a previous alcohol beverage drinker. He used to be a heavy
cigarette smoker consuming 1 pack per day for about 23 years. He quit smoking about 7 years ago. He goes walking
30 minutes to an hour 3x a week. He is not into any sports activity.
He is a fast-eater, finishing his meal in 10-15 minutes. He consumes 5-6 cans of carbonated drinks a day
(Coca-Cola). He never misses his breakfasts. His sample diet is as follows:
Breakfast
Time
6-7 am
Morning
Snack
9-10 am
Where
Home
Office/school
With whom
Duration
Type of food
Family
15 minutes
Bacon, egg,
Spam, Vigan
or Lucban
Longganisa,
fried rise
Officemates
30 minutes
Pancit,
ginataan,
sandwich w/
mayonnaise,
spaghetti
Lunch
1130-12
noon
Office
Officemates
1 hour
Pork or
chicken, 2
cups rice
Afternoon
Snack
3-4 pm
Dinner
Same as
morning
snack
Restaurant
serving
buffet food or
eat-all-you
can
Friends
1 hour
Buffet or eatall-you can
(pork, crispy
pata, peking
duck, lechon
de leche)
Same as
morning
snack
7-8 pm
Bedtime
Snack
(rarely)
Home
Chips
Physical Examination:
He is conscious, coherent, oriented to 3 spheres, ambulatory and not in cardio-pulmonary distress.
Vital Signs:
BP 120/80 mmHg PR 76/min
weight 125 kgs height 170 cms
BMI 43.25 kg/m2
WC 141 cms
Anicteric sclerae, pink palpebrae, (+) acanthosis nigricans, no thyromegaly, no neck vein engorgement
Symmetrical chest expansion, clear breath sounds
Adynamic precordium, normal weight, regular rhythm, no murmurs
Globular abdomen, no violaceous striae, normoactive bowel sounds, soft, non-tender
Full pedal pulses, no pitting pedal edema
Laboratory Work-up:
Complete Blood Count
Hemoglobin
10.30 g/dL
Hematocrit
32.40%
RBC
4.06 x 106/uL
WBC
5.68 x 106/uL
Platelet
253,000/uL
Blood Chemistry
HbA1c
FBS
BUN
Creatinine
SGPT
SGOT
Albumin
13.40%
230.79 mg/dL
52.01 mg/dL
2.70 mg/dL
42.00 U/L
19.00 u/L
3.40 g/dL
Differential Count:
Basophils
Eosinophils
Segmenters
Lymphocytes
Monocytes
Total Cholesterol
HDL Cholesterol
LDL Cholesterol
Triglycerides
161.35 mg/dL
32.89 mg/dL
109.11 mg/dL
313.60 mg/dL
1%
5%
61 %
25 %
8%
Thyroid Function Tests
FT4
13.842 pmol/L
TSH
2.265 uIU/mL
Myocardial Perfusion Imaging
Abnormal Myocardial Perfusion Imaging.
Mild stress-induced myocardial ischemia in the inferior region can not be ruled out.
Over-all left ventricular systolic function was normal.
Chest X-ray:
Normal Chest
12-lead EKG: Incomplete Right Bundle Branch Block
2-D Echocardiography with Doppler Study
Concentric left ventricular hypertrophy with normal wall motion and contractility. Normal computed
left ventricular ejection fraction of 62%.
Mitral regurgitation, trace. Aortic regurgitation, trace. Prolonged IVRT compatible with decreased
left ventricular relaxation. Normal pulmonary artery pressure.
Liver Ultrasonography:
Fatty Liver
Pulmonary Function Test:
Normal Spirometry, Lung Volumes and DLCO
Working Diagnoses:
Obese Class II
Diabetes Mellitus type 2, insulin-requiring, uncontrolled
Dyslipidemia
Hypertensive Atherosclerotic Coronary Artery Disease, not in Congestive Heart Failure
Obstructive Sleep Apnea
Chronic Kidney Disease secondary to diabetic nephropathy vs hypertensive nephrosclerosis
Bronchial Asthma not in exacerbation
Benign Prostatic Hypertrophy
Course in the Ward:
Upon admission, he was referred back to the following services: cardiology, nephrology, pulmonology, and
surgery. On the 1st hospital day, he underwent laparoscopic adjustable gastric banding. The surgery was uneventful.
Insulin drip was started post-operatively. He was placed back on CPAP. On the 2nd hospital day, he was started on
clear liquid diet. Insulin drip was then shifted to subcutaneous insulin with very minimal requirement. He was sent
home with the advice to have clear liquid diet for the next two weeks then to progress to general liquid diet thereafter.
Follow-up
On follow-up after a month, he has lost weight of 31 pounds. Presently, he weighs 231 pounds. His insulin
requirements are minimal, requiring only 24 units a day. His blood pressure is now normal at 120-130/80 mmHg. He
is able to sleep without his CPAP. He no longer pants on walking, and his snoring has been infrequent.