Addressing Vitamin Deficiencies in a Patient with Amputation and History of Roux-en-y Gastric Bypass

Case Diagnosis: Vitamin Deficiencies in Patient with Amputation and History of Roux-en-y Gastric Bypass

Case Description or Program Description: Fifty-year-old female with history of Roux-en-Y and left hallux amputation presented to acute rehabilitation center status post right transmetatarsal amputation. Metabolic workup for altered mental status during rehab included vitamin panel, for which patient was diagnosed with severe protein-calorie malnutrition, hypovitaminosis A, B12, D and E, as well as hypomagnesemia, hypokalemia, hypophosphatemia, zinc and copper deficiency.

Setting: Acute Inpatient Rehabilitation Setting

Assessment/Results: Patient was placed on oral Vitamin A, D, E, monthly Vitamin B12 injection and minerals and electrolytes were replenished. Nutrition team was consulted; patient was placed on twice daily multivitamin and protein supplementation to augment healing after amputation. Despite successful discharge, patient subsequently required multiple readmissions for debility, further affecting patient’s ability to continue rehab and preventing community re-integration after amputation.

Discussion (relevance): There is sparse amount of literature reporting the impact of vitamin deficiencies on the rehabilitation of patients with amputation. Patients prone to amputation often initially present with malnutrition and poor oral intake. Nutritional optimization is particularly important for wound healing status post lower extremity amputation where blood flow is less compared to the upper extremity. Studies have shown worse outcomes with low vitamin A, B12 and C in this population, and vitamin D deficiencies have shown higher risk of infection and amputation in patients with diabetic foot ulcers.

Conclusions: This case illustrates the importance of addressing vitamin deficiencies early in the clinical course and the optimization of nutrition in this patient population. Obtaining a vitamin panel, in patients particularly vulnerable to vitamin deficiencies (most commonly Vitamin C, D, B12, zinc) such as patients with history of Roux-en-Y can provide information on the adequacy of oral intake of rehab patients. A multidisciplinary approach is essential, particularly involving a nutrition team to provide recommendations on supplementation during the rehab course.