Vitamin D deficiency following Billroth II surgery - How much vitamin D is enough?: a case report

Abstract

Background

Vitamin D deficiency with all its consequences is a global health problem.

Case Presentation

We reported a 62-year-old Caucasian woman with alcohol-related liver cirrhosis (Child class A) and a medical history of Billroth II surgery. Although she has taken an oral dose of 16 800 IU vitamin D daily for six weeks to normalise her 25-hydroxyvitamin D level the raise was only moderate.

Conclusion

High-dose oral or parenteral vitamin D therapy is necessary to gain sufficient 25-hydroxyvitamin D serum levels in patients following gastric surgery.

Background

Vitamin D deficiency is defined as 25-hydroxyvitamin D serum levels below 20 ng/ml; levels ≥20 and <30 ng/ml indicate an inadequate vitamin D status. Approximately 1 billion people worldwide have 25-hydroxyvitamin D levels below 30 ng/ml[1]. The major source of vitamin D is sunlight, which promotes subcutaneous production of vitamin D under the influence of UVB light; only 15-20% of vitamin D in the body derives from food. Apart from musculoskeletal malfunction (eg. osteomalacia, osteoporosis, muscle weakness, falls), vitamin D deficiency seems to be associated with several other diseases, e.g. cancer and cardiovascular or immunological disorders[2]. Corresponding trials demonstrated that a daily vitamin D intake of 800-1000 IU is needed to achieve and maintain 25-hydroxyvitamin D levels between 70-80 nmol/l, which are considered to be optimal for fracture prevention[3].

Case Presentation

A 62-year-old female Caucasian was admitted to our endocrinology outpatient clinic for evaluation of osteoporosis. The patient had a history of partial gastrectomy with Billroth II reconstruction due to multiple gastric ulcers 27 years previously, and liver cirrhosis (Child A) of more than 15 years' standing due to a period of alcoholism as well as local breast cancer in 2003. For treatment of portal hypertension and recurrent ascites, she was being treated with propranolol, furosemide and spironolactone.

A fasting blood sample taken the morning after admission produced the following results: elevated liver transaminases (GGT 242 U/l [<38], AST 49 U/l [<30]), but unimpaired liver function. Blood count and other parameters were within normal limits. Specific analysis showed low 25-hydroxyvitamin D (20 ng/ml [30.0-60.0]) with normal serum PTH, but elevated levels of bone-specific alkaline phosphatase (74.3 μg/l [7.1-21.3]) and β-Crosslaps (0.53 ng/ml [0.09-0.44]), reflecting accelerated bone turnover. Standardized x-ray of the spine showed hyperkyphosis but no fractures. DXA measurement at the spine and the hip revealed osteopenia with a T-score of -1.8 SD and -2.0 SD, and osteoporosis at the distal forearm with a T-score of -2.8 SD.

The patient was advised to take an oral dose of 16 000 IU (40 drops) of vitamin D 3 per week combined with a daily supplement of 1000 mg calcium and 800 IU vitamin D 3.

At 6 weeks' follow-up, she reported that she had taken 40 drops of vitamin D 3 daily, resulting in a cumulative intake of 705 600 IU in that period. Blood analysis then showed 35 ng/ml 25-hydroxyvitamin D, with a surprisingly small increase of 15 ng/ml.

Discussion

Oral treatment with 1000 IU vitamin D daily over a period of 3-4 months raises 25-hydroxyvitamin D by about 10 ng/ml[4]. Based on this, an increase of 168 ng/ml would be expected with a daily vitamin D intake of 16 800 IU. The increase of just 15 ng/ml was a surprise. The history of Billroth II may, however, have had a negative impact on absorption, although the enteral absorption of the fat-soluble vitamin D takes place in the duodenum and the proximal jejunum, sections of the gut that are not removed as part of a Billroth II resection.

The exact mechanism of the development of vitamin D deficiency in patients following gastric surgery is not yet known. Malabsorption due to accelerated intestinal passage, impaired secretion of pancreatic enzymes and bacterial overgrowth may lead to steatorrhea [5] and so to avoidance of food rich in vitamin D, which could also contribute to vitamin D deficiency[6].

Conclusion

Vitamin D toxicity has recently become a controversial issue. According to the literature, a vitamin D intake of 10 000 IU daily does not cause intoxication in the sense of 25-hydroxyvitamin D levels above 150 ng/ml associated with hypercalcemia and hyperphosphatemia, even in healthy people[1, 7]. Some special groups of patients may need even higher doses of supplementation to achieve satisfactory serum vitamin D levels. This case demonstrates that patients with a history of gastrointestinal surgery may need either high-dose oral vitamin D supplementation or even parenteral administration.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.