Skip to content


  • Case Report
  • Open Access

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

  • 1,
  • 2,
  • 1,
  • 3 and
  • 1Email author
Cases Journal20103:12

  • Received: 15 October 2009
  • Accepted: 8 January 2010
  • Published:



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.


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


  • Hyperphosphatemia
  • Steatorrhea
  • Daily Vitamin
  • Elevated Liver Transaminase
  • Cumulative Intake


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.


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].


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.




gamma glutamyl-transferase


aspartate transaminase


parathyroid hormone


dual-energy x-ray absorptiometry.



The authors want to thank Prof. Barbara Obermayer-Pietsch and her team for the laboratory analysis.

Authors’ Affiliations

Department of Internal Medicine, Division of Endocrinology and Nuclear Medicine, Medical University Graz, Auenbruggerplatz 15, Graz, 8036, Austria
Department of Surgery, Division of Transplantation Surgery, Medical University Graz, Auenbruggerplatz 29, Graz, 8036, Austria
Department of Internal Medicine, Division of Endocrinology and Nuclear Medicine, Medical University Graz, Auenbruggerplatz 29, Graz, 8036, Austria


  1. Holick MF: Vitamin D Deficiency. N Engl J Med. 2007, 357: 266-281. 10.1056/NEJMra070553.View ArticlePubMedGoogle Scholar
  2. Holick MF: High Prevalence of Vitamin D Inadequacy and Implications for Health. Mayo Clin Proc. 2006, 81 (3): 353-373. 10.4065/81.3.353.View ArticlePubMedGoogle Scholar
  3. Dawson-Hughes B, Heaney RP, Holick MF, Lips P, Meunier PJ, Vieth R: Estimates of optimal vitamin D status. Osteoporos Int. 2005, 16: 713-716. 10.1007/s00198-005-1867-7.View ArticlePubMedGoogle Scholar
  4. Cannell JJ, Hollis BW: Use of Vitamin D in Clinical Practice. Altern Med Rev. 2008, 13 (1): 6-20.PubMedGoogle Scholar
  5. Thieler S, Schölmerich J: Gastrointestinale Erkrankungen und Osteomalazie. Internist. 2008, 49: 1197-1205. 10.1007/s00108-008-2117-9.View ArticlePubMedGoogle Scholar
  6. Tovey FI, Hobsley M: Post-gastrectomy patients need to be followed up for 20-30 years. World J Gastroenterol. 2000, 6 (1): 45-48.View ArticlePubMedGoogle Scholar
  7. Vieth R: Why the optimal requirement for vitamin D3 is probably much higher than what is officially recommended for adults. J Steroid Biochem Mol Biol. 2004, 89-90: 575-579. 10.1016/j.jsbmb.2004.03.038.View ArticlePubMedGoogle Scholar


© Sampl et al; licensee BioMed Central Ltd. 2010

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.