Evaluations of Gallbladder Disease And Function
April 11, 2015 7:03 am
Gallbladder disease can include both anatomical and functional condition. We are familiar with gallstones. Bile acids, Lecithin (a phospholipid), and cholesterol are present in the Bile. When the proportional percentage of each one of them is outside a very narrow range, gallstones are formed. Approximately 75% of the gallstones are formed because of the supersaturation of the content of the gallbladder with cholesterol which results in cholesterol stone formation. The rest are pigmented stones.
Gallstones are usually identified by ultrasound and they are seen as shadows.
There are patients that have a normal gallbladder ultrasound result that continue to have signs and symptoms of gallbladder disease, such as abdominal pain in the right upper quadrant, nausea and vomiting with fatty meals, and bloating to name a few. These patients should be evaluated by a dynamic HIDA scan.
A dynamic HIDA scan study evaluates the function of the gallbladder, by creating a movie of the gallbladder, where as an ultrasound takes pictures of the gallbladder.
In a dynamic HIDA scan, and contractility of the gallbladder is reported in form of ejection fraction (%EF). This represent the amount of gallbladder contraction in response to the stimulation by a fatty meal mediated thru cholecystokinin (CCK). A normal EF is greater that 35%. Anything less than than with the sign and symptoms of gallstones, should be highly suspect for acalculous cholecystitis. Calculus because there is no stone.
(The bright white collection represents the filling of the gallbladder)
This short movie represents the uptake of the radio nuclear material in the gallbladder and its normal secretion in the small bowel.
These are the static images before the injection of CCK.
Following the injection, digital subsection of the images measure the amount of nuclear activity of the gallbladder before and after contraction and an Ejection Fraction is calculated.
Vitamin K1
April 08, 2015 7:16 pm
Vitamin K1 is a found in dark green leafy vegetables, asparagus, brussels sprouts, some grains, olive oil, prunes, soy bean oil, and canola oil. The body has limited storage capacity for Vitamin K and uses a recycle system to reuse it.
Vitamin K1 is a fat-soluble vitamin that after Duodenal Switch is not as easily absorbed due to the limiting contact of the food product with the bile until the common channel. Bile is needed to absorb fatty acids and fat-soluble vitamins.
Duodenal Switch patients in need of Vitamin K1 supplements should take “Dry” or water miscible type of Vitamin K1, such as Biotech brand. The patients laboratory studies will determine if a patient requires Vitamin K1 supplement. Duodenal Switch patients should have laboratory studies drawn and evaluated at least on a yearly basis. Vitamin K works in a delicate balance with other supplements and should be monitored by a physician, in at risk people.
Vitamin K1 is most know for it’s coagulation effect and the clotting cascade. Vitamin K1 works with calcium and proteins in order to accomplish coagulation synethesis. Care should be taken with Vitamin K supplementation and anti-coagulation (blood thinners) therapy. Please see your physician regarding any supplementation of Vitamin K and blood thinner medications.
A discovery of Vitamin K dependent proteins has led to research on Vitamin K1 in bone health. Bone matrix proteins, specifically osteocalcin, undergo gamma carboxylation with calcium much the way coagulation factors do; this process also requires Vitamin K. Osteocalcin is a Gla-protein that is regulated by Vitamin D. The calcium binding ability of osteocalcin requires several Vitamin K carboxylations to exert it’s effects on bone mineralization.
In adults, the causes of Vitamin K1 deficiency include the following :
Chronic illness
Malnutrition
Alcoholism
Multiple abdominal surgeries
Long-term parenteral nutrition
Malabsorption
Cholestatic disease
Parenchymal liver disease
Cystic fibrosis
Inflammatory bowel disease
Medications: Antibiotics (cephalosporin), cholestyramines, warfarin, salicylates, anticonvulsants, Cefamandole, cefoperazone, salicylates, hydantoins, rifampin, isoniazid, barbiturates, and certain sulfa drugs, higher Vitamin E can antagonized Vitamin K)
Massive transfusion
Disseminated intravascular coagulation (DIC) – Severe
Chronic kidney disease/hemodialysis
Additional information: https://lpi.oregonstate.edu/infocenter/vitamins/vitaminK/
Intake of Vitamin K1 and K2 and bone fracture risk
As always, discuss with your physicians and/or surgeon any changes in medications and supplements. This is not meant to be an all inclusive discussion of Vitamin K.
Shared Success Story- Odessa D.
April 07, 2015 10:20 am
My name is Odessa D. I am going to talk about my weight loss journey with the lap band which started in 2006. At my heaviest I weighed 270 pounds and was a size 24 waist. I had high blood pressure, was a border line diabetic, had lower back pain, I had no energy, I was tired all the time, and I had sleep apnea.
My family doctor had suggested weight loss surgery but I was hesitant because I was afraid of surgery. Until one night my 8 year old daughter found me not breathing in my sleep. I made the decision to go through with the surgery.
Prior to surgery I did as much research as I could about the lap band. At the time I felt it was the right decision. On the day of the surgery everything went well. The first few months were great. I was losing weight, feeling good, feeling happy, and healthier then I have in years.
Then it began, all the symptoms of a slipped band. I started vomiting, nausea, acid reflux, and I was having trouble drinking and eating on a daily basis. My doctor confirmed it was a slipped band. We decided to replace the band because I was still overweight. On day of surgery I weighed 210 lbs.
After a month I started having symptoms of a slipped band. My doctor performed x-rays but everything looked fine. After 2 years with these symptoms and numerous doctor visits and x-rays I just gave up and learned to live with it. In 2 years I lost 4 lbs. My high blood pressure and sleep apnea came back. I finally decided to get the lap band removed. I wanted my life back and if that meant gaining the weight back that I lost then I was willing to make that sacrifice.
Dr. Keshishian was referred to me by 2 of his past patients. From the moment I walked into his office I was already at ease. When I first met Dr. Keshishian, I knew I was in good hands and I knew he could help me. He confirmed I had another slipped band and a detached port. At this point we discussed removing the lap band and switching to the Sleeve Gastrectomy. Finally everything was going to be fixed and everything was going to be right.
I can’t express how much my life has improved since removing the second band and switching to the sleeve. I have lost 46 pounds in 9 months. I now weigh 160 pounds and wear a size 8 waist. Now I look forward to each and every day with joy and pleasure knowing I don’t have to deal with a bad band and all the horrible symptoms that came with it.
Since the surgery and losing more weight I have been very active. I go hiking almost every weekend. I have literally climbed a mountain! I did my first 5k mud obstacle course in which my second 5k is in October. I even have a purple Mohawk! I have 100% confidence in myself and in everything that I do. My life has greatly improved since the sleeve. All thanks to Dr. Keshishian. It has been a very bumpy road with my weight loss journey but Dr. Keshishian has smoothed out the bumps and I plan on traveling the distance with many adventures along the way.
I would like to leave a huge “Thank You” to Dr. Keshishian and his staff. Thank you for making me feel welcomed, being friendly, making me feel comfortable, and especially for giving my life back to me. I can’t wait to see what the future holds for me and my family!
Thank you Dr. Keshishian and staff!
Odessa D.
First Duodenal Switch Patient- Dr. Hess
April 05, 2015 3:35 pm
I had the opportunity to be in a meeting with Dr. Hess in November of 2004. He presented a lecture about the history of the Duodenal Switch and his collaborative work with Dr. Scopinaro, the pioneer surgeon of the Biliopancreatic Diversion. The BPD was the the foundation of the Duodenal Switch operation. The first patient ever to have had the Duodenal Switch was a revision from a failed vertical banded March of 1988 by Dr. Douglas Hess. At the time of this particular meeting (in 2004), the patient was 17.5 years post op.
This is a copy of the slide that he shared with the surgeons present at the Duodenal Switch meeting on November 21, 2004.
BADAS-Bowel Associated Dermatosis Arthritis Syndrome
April 05, 2015 9:51 am
https://www.mayoclinicproceedings.org/article/S0025-6196(12)60341-3/fulltext
https://www.ncbi.nlm.nih.gov/pubmed/6694433
https://www.ncbi.nlm.nih.gov/pubmed/21332683
Pregnancy Post Bariatric Surgery
April 04, 2015 8:11 am
Pregnancy Webinar Post Bariatric Surgery
Vitamin B6 Toxicity
April 01, 2015 7:58 pm
In recent years, we have noticed a trend of increased Vitamin B6 (Pyroxidine) levels in post Duodenal Switch patients’ laboratory studies. Vitamin B6 is a water soluble vitamin, however, toxicity can happen with an increase in supplementation. The increased availability and amounts of Vitamin B6 in more supplements such as Calcium, multivitamins and B Complex supplements could be the cause of the trend post weight loss surgery. Please be sure to check the amounts of Vitamin B6 within your daily supplements.
Vitamin B6 Function:
Vitamin B6 is an important water soluble vitamin which functions as co-enzymes in a number of metabolic pathways including amino acids, fatty acids, glycogen, and steroid hormones (estrogen, cortisol, androgens and Vitamin D) metabolism. Other biological functions are hemoglobin synthesis, immune function and inflamation, neurotransmission and gene expression. B6 has been shown to improve carpal tunnel syndrome, PMS, AADHD, Alzheimer’s, acne, lung cancer, high homocysteine levels, asthma, kidney sones, and some cases of depression and arthritis. The U.S. Daily Recommended dose ins 1.2-2mg for adults.
Toxicity has most often happened from increased supplementation and rarely from food alone except for in a subset of people who may have increased sensitivity, gene mutations or other issues with Vitamin B6. In the average person, doses of 1000mg per day which is about 800 times the daily amount from food can cause neuropathy and neurotoxicity. There have been instances of toxicity issues at doses of 500mg daily. Other symptoms associated with high levels of B6 are skin rashes, nausea, vomiting, loss of appetite, increased liver function tests, sensitivity to sunlight. Nerve damage or numbness and tingling of the feet, legs and hand, if left untreated, can become irreversible. Stop taking B6 if you experience any of these symptoms. The daily U.S. no adverse effects dose is set at a max of 200mg daily. The daily recommend max limit is 100mg daily.
Drug interactions with high doses of B6 levels are phenobarbital, phenytoin and L-Dopa and cause decrease effectiveness. B6 deficiency is a side effect of oral contraceptives, isoniazid, cycloserine, pencil amine, methylxanthines, and long term NSAIDs use due to impaired Vitamin B6 metabolism.
Once B6 levels are elevated it is important to to try to decrease intake as much as possible and levels will usually drop in weeks to months. Read your labels of drinks, energy drinks, multi-vitamin, cold supplements, high B6 foods, protein supplements, and other sources. These are items that typically have added high levels of B6 supplement. You can also avoid group Vitamin B supplements and go to individual B vitamins that are needed.
Additional information on Vitamin B6. Please have your surgeon or your primary care physician review your laboratory studies. Seek medical attention if you are experiencing any of the above symptoms or any other unusual symptoms.
Medications that negatively affect bone loss and contribute to Osteoporosis (Moved)
March 31, 2015 4:07 pm
An Example of Medications that may cause bone loss
It should be noted that this list is NOT all inclusive and gives the type of medication but does not list all the medications in that category that may affect bone health. I would also like to point out that the Proton Pump Inhibitor labels should probably be changed to “Acid Reducers” as reducing acid is the issues. https://americanbonehealth.org
Hyperparathyroidism and Weight Loss Surgery
March 13, 2015 5:57 pm
Hypoparathyroidism refers to elevated level of parathyroid hormone levels (elevated or high PTH). Parathyroid glands are two small glands that are located behind the thyroid gland. The primary function is regulation of the calcium level in the bloodstream. Parathyroid levels may be abnormally elevated for a number of reasons.
1-Primary Hyperparathyroidism
There may be abnormalities within the parathyroid glands themselves including benign and malignant tumors. Laboratory studies to assist in identifying Parathyroid hyperplasia are calcium, phosphorus, magnesium, PTH (parathyroid hormone), Vitamin D and possibly a 24 hour urine, kidney x-ray, and Dexa scan. The calcium levels in parathyroid hyperplasia are usually elevated and Vitamin D levels low. Patients can present with hypercalcemia symptoms such as kidney stones, nausea, vomiting, peptic ulcer, constipation, bone pain, bone weakness, depression, lethargy, fatigue. There are two types of Primary Hyperparathyroidism parathyroid hyperplasia and parathyroid adenomas. These both can at times be genetically linked.
Once the cause of elevated parathyroid hormone has been identified as primary hyperparathyroidism, the treatment involves surgical removal of one or more of the adenoma(s) or removal of 3.5 off all of the parathyroid glands if hyperplasia is diagnosed.
Parathyroid hyperplasia: When the growth involves all 4 of the glands. These may effect either one of the glands or all 4 of them. Majority of these are benign.
Parathyroid adenoma(s) refers to the abnormality or benign growth of one or more of the parathyroid glands.
2- Secondary Hyperparathyroidism
This is probably the most common cause of hyperparathyroidism imposed on a weight loss surgical patient. The elevated parathyroid hormone is the physiologic response all of the parathyroid glands to low calcium level. The parathyroid hormone is elevated in order to favor bone breakdown and make available for calcium to be circulating in the bloodstream. Parathyroid hormone also facilitates reabsorption of the calcium from the urine and improve absorption of the calcium from the GI tract.
The most common causes of secondary hyperparathyroidism is Vitamin D deficiency, weight loss surgery, kidney failure, Celiac or Crohn’s Disease. Lower levels of Vitamin D decrease the intestinal calcium absorption and thereby increasing PTH secretion. Vitamin D is the transport molecule for calcium. Symptoms may include bone or joint pain, muscle weakness, osteomalacia, low to normal blood calcium levels. The treatment of secondary hyperparathyroidism is correction of the underlying low calcium, low vitamin D levels. We have our Duodenal Switch patients take calcium citrate and dry water miscible type of Vitamin D3. Some people may require vitamin D injection in order to overcome deficiencies. You can find a list of supplements on our website and/or our starting point supplement recommendation in our patient workbook
Articles on Secondary Hyperparathyroidism following Weight Loss Surgery:
https://www.ncbi.nlm.nih.gov/pubmed/23015268
https://www.ncbi.nlm.nih.gov/pubmed/16354517
“Obesity Docs Should Consider Duodenal Switch”
March 10, 2015 3:10 pm
Obesity Doctors Should Consider Duodenal Switch
by Dr. Ara Keshishian
Recent article published on MEDPAGE.com
