Publications by authors named "Timothy R Koch"

39 Publications

Laparoscopic Vertical Sleeve Gastrectomy as a Treatment Option for Adults with Diabetes Mellitus.

Adv Exp Med Biol 2021 ;1307:299-320

Center for Advanced Laparoscopic General & Bariatric Surgery, MedStar Washington Hospital Center and Georgetown University School of Medicine, Washington, DC, USA.

Obesity is a major factor in the worldwide rise in the prevalence of type 2 diabetes mellitus. The obesity "epidemic" will require novel, effective interventions to permit both the prevention and treatment of diabetes caused by obesity. Laparoscopic vertical sleeve gastrectomy is a newer bariatric surgical procedure with a lower risk of complications (compared to Roux-en-Y gastric bypass surgery). Based in part on restriction of daily caloric intake, sleeve gastrectomy has a major role in inducing significant weight loss and weight loss is maintained for at least 10 years. Prior studies have supported the utility of the vertical sleeve gastrectomy for the treatment and management of subgroups of individuals with diabetes mellitus. There are reports of 11% to 76.9% of obese individuals discontinuing use of diabetic medications in studies lasting up to 8 years after vertical sleeve gastrectomy. Major ongoing issues include the preoperative determination of the suitability of diabetic patients to undergo this bariatric surgical procedure. Understanding how this surgical procedure is performed and the resulting anatomy is important when vertical sleeve gastrectomy is being considered as a treatment option for diabetes. In the postoperative periods, specific macronutrient goals and micronutrient supplements are important for successful and safer clinical results. An understanding of immediate- and long term- potential complications is important for reducing the potential risks of vertical sleeve gastrectomy. This includes the recognition and treatment of postoperative nutritional deficiencies and disorders. Vertical sleeve gastrectomy is a component of a long term, organized program directed at treating diabetes related to obesity. This approach may result in improved patient outcomes when vertical sleeve gastrectomy is performed to treat type 2 diabetes in obese individuals.
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http://dx.doi.org/10.1007/5584_2020_487DOI Listing
January 2021

Prolonged Hypercupremia after Laparoscopic Vertical Sleeve Gastrectomy Successfully Treated with Oral Zinc.

Case Rep Gastrointest Med 2019 4;2019:8175376. Epub 2019 Jun 4.

Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA.

A 30-year-old female underwent vertical sleeve gastrectomy. Postoperatively, hypercupremia and elevated ceruloplasmin were identified. Further testing revealed normal blood levels of transaminases, alkaline phosphatase, and albumin. She stopped ingestion of multivitamins, began a copper-free multivitamin, and then began a low copper diet, but with no improvement in hypercupremia. Protein electrophoresis was normal with no M-spike. Urinary copper excretion was normal at 0.24 micromol/24 hours (normal: < 0.55), and there were no Kayser-Fleischer rings on slit lamp examination. Two years postoperatively, she lost 44% of excess preoperative weight and she began zinc sulfate before meals twice daily (115 mg elemental Zinc/day). At 2 months and 8 months later, plasma copper and ceruloplasmin had essentially normalized. Increased production of ceruloplasmin could have been a response to significant weight loss or the presence of nonalcoholic steatohepatitis. The mechanism of zinc's beneficial effect is uncertain but may be related to suppressing hepatic synthesis of or secretion of ceruloplasmin.
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http://dx.doi.org/10.1155/2019/8175376DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6582827PMC
June 2019

Bowel symptoms are associated with hypovitaminosis D in individuals with medically complicated obesity.

Nutr Res 2019 03 8;63:70-75. Epub 2018 Dec 8.

Center for Advanced Laparoscopic General & Bariatric Surgery, MedStar Washington Hospital Center and Georgetown University School of Medicine, Washington, DC 20010. Electronic address:

We reported that 30% of individuals with medically complicated obesity have bowel symptoms, suggesting irritable bowel syndrome, but this prevalence of bowel symptoms is not related to body mass index or diabetes mellitus. Hypovitaminosis D is common in individuals with obesity and type 2 diabetes mellitus and is associated with depressive symptoms. Because antidepressants improve global symptoms in individuals with bowel symptoms, we hypothesize that the high prevalence of bowel symptoms in medically complicated obesity is associated with hypovitaminosis D. This is a single-institution, retrospective cohort study performed in a large, urban community teaching hospital. Over 2 years, individuals considering bariatric surgery completed a Manning symptom questionnaire to quantify bowel symptoms. Serum 25-hydroxy vitamin D was ordered, and the results were recorded for all individuals. Among 271 subjects, 229 subjects (80% women, 20% men; 67% black, 31% white; age range: 23-73 years; body mass index range: 35-91 kg/m) completed 25-hydroxy vitamin D testing. Sixty-seven subjects (29%) have 3 to 6 Manning bowel symptoms, suggesting irritable bowel syndrome; 84 (37%) have type 2 diabetes; and 180 (79%) had vitamin D insufficiency. There are significant negative associations between Manning bowel symptoms and vitamin D concentrations in subjects with obesity (P = .01) and with type 2 diabetes mellitus and obesity (P = .007). The results support our hypothesis that the high prevalence of bowel symptoms in people with medically complicated obesity is associated with hypovitaminosis D. A prospective study is required to evaluate vitamin D supplementation and relief of bowel symptoms in people with medically complicated obesity.
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http://dx.doi.org/10.1016/j.nutres.2018.12.002DOI Listing
March 2019

Current and future impact of clinical gastrointestinal research on patient care in diabetes mellitus.

World J Diabetes 2018 Nov;9(11):180-189

Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States.

The worldwide rise in the prevalence of obesity supports the need for an increased interaction between ongoing clinical research in the allied fields of gastrointestinal medicine/surgery and diabetes mellitus. There have been a number of clinically-relevant advances in diabetes, obesity, and metabolic syndrome emanating from gastroenterological research. Gastric emptying is a significant factor in the development of upper gastrointestinal symptoms. However, it is not the only mechanism whereby such symptoms occur in patients with diabetes. Disorders of intrinsic pacing are involved in the control of stomach motility in patients with gastroparesis; on the other hand, there is limited impact of glycemic control on gastric emptying in patients with established diabetic gastroparesis. Upper gastrointestinal functions related to emptying and satiations are significantly associated with weight gain in obesity. Medications used in the treatment of diabetes or metabolic syndrome, particularly those related to pancreatic hormones and incretins affect upper gastrointestinal tract function and reduce hyperglycemia and facilitate weight loss. The degree of gastric emptying delay is significantly correlated with the weight loss in response to liraglutide, a glucagon-like peptide-1 analog. Network meta-analysis shows that liraglutide is one of the two most efficacious medical treatments of obesity, the other being the combination treatment phentermine-topiramate. Interventional therapies for the joint management of obesity and diabetes mellitus include newer endoscopic procedures, which require long-term follow-up and bariatric surgical procedure for which long-term follow up shows advantages for individuals with diabetes. Newer bariatric procedures are presently undergoing clinical evaluation. On the horizon, combination therapies, in part directed at gastrointestinal functions, appear promising for these indications. Ongoing and future gastroenterological research when translated to care of individuals with diabetes mellitus should provide additional options to improve their clinical outcomes.
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http://dx.doi.org/10.4239/wjd.v9.i11.180DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6242723PMC
November 2018

Organization of future training in bariatric gastroenterology.

World J Gastroenterol 2017 Sep;23(35):6371-6378

Professor Emeritus, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, United States.

A world-wide rise in the prevalence of obesity continues. This rise increases the occurrence of, risks of, and costs of treating obesity-related medical conditions. Diet and activity programs are largely inadequate for the long-term treatment of medically-complicated obesity. Physicians who deliver gastrointestinal care after completing traditional training programs, including gastroenterologists and general surgeons, are not uniformly trained in or familiar with available bariatric care. It is certain that gastrointestinal physicians will incorporate new endoscopic methods into their practice for the treatment of individuals with medically-complicated obesity, although the long-term impact of these endoscopic techniques remains under investigation. It is presently unclear whether gastrointestinal physicians will be able to provide or coordinate important allied services in bariatric surgery, endocrinology, nutrition, psychological evaluation and support, and social work. Obtaining longitudinal results examining the effectiveness of this ad hoc approach will likely be difficult, based on prior experience with other endoscopic measures, such as the adenoma detection rates from screening colonoscopy. As a long-term approach, development of a specific curriculum incorporating one year of subspecialty training in bariatrics to the present training of gastrointestinal fellows needs to be reconsidered. This approach should be facilitated by gastrointestinal trainees' prior residency training in subspecialties that provide care for individuals with medical complications of obesity, including endocrinology, cardiology, nephrology, and neurology. Such training could incorporate additional rotations with collaborating providers in bariatric surgery, nutrition, and psychiatry. Since such training would be provided in accredited programs, longitudinal studies could be developed to examine the potential impact on accepted measures of care, such as complication rates, outcomes, and costs, in individuals with medically-complicated obesity.
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http://dx.doi.org/10.3748/wjg.v23.i35.6371DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5643262PMC
September 2017

Prevalence of clinical thiamine deficiency in individuals with medically complicated obesity.

Nutr Res 2017 Jan 1;37:29-36. Epub 2016 Dec 1.

Center for Advanced Laparoscopic General & Bariatric Surgery, MedStar-Washington Hospital Center and Georgetown University School of Medicine, Washington, DC 20010, USA. Electronic address:

Thiamine is a vitamin whose deficient can result in multiorgan symptoms. We described an 18% prevalence of clinical thiamine deficiency after gastric bypass surgery. Our hypotheses are that individuals with medically complicated obesity frequently have clinical thiamine deficiency and that diabetes mellitus is a mechanism for development of clinical thiamine deficiency. This is a single institution, retrospective observational study of consecutive patients with a body mass index of at least 35 kg/m who were evaluated in preoperative gastrointestinal bariatric clinic from 2013 to 2015. Each patient underwent a symptom survey. Clinical thiamine deficiency is defined by both (1) consistent clinical symptom and (2) either a low whole-blood thiamine concentration or significant improvement of or resolution of consistent clinical symptoms after receiving thiamine supplementation. After excluding 101 individuals with prior bariatric surgery or heavy alcohol consumption, 400 patients were included in the study. Sixty-six patients (16.5% of 400) fulfill a diagnosis of clinical thiamine deficiency, with 9 (14% of 66) having consistent gastrointestinal manifestations, 46 (70% of 66) having cardiac manifestations, 39 (59% of 66) having peripheral neurologic manifestations, and 3 (5% of 66) having neuropsychiatric manifestations. Diabetes mellitus is not a risk factor (P=.59). Higher body mass index is a significant risk for clinical thiamine deficiency (P=.007). Clinical thiamine deficiency is common in these individuals and a higher body mass index is an identified risk factor. Mechanisms explaining development of thiamine deficiency in obese individuals remain unclear.
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http://dx.doi.org/10.1016/j.nutres.2016.11.012DOI Listing
January 2017

Dysphagia after vertical sleeve gastrectomy: Evaluation of risk factors and assessment of endoscopic intervention.

World J Gastroenterol 2016 Dec;22(47):10371-10379

Anand Nath, Department of Medicine, MedStar-Washington Hospital Center and Georgetown University School of Medicine, Washington, DC 20010, United States.

Aim: To evaluate the risks of medical conditions, evaluate gastric sleeve narrowing, and assess hydrostatic balloon dilatation to treat dysphagia after vertical sleeve gastrectomy (VSG).

Methods: VSG is being performed more frequently worldwide as a treatment for medically-complicated obesity, and dysphagia is common post-operatively. We hypothesize that post-operative dysphagia is related to underlying medical conditions or narrowing of the gastric sleeve. This is a retrospective, single institution study of consecutive patients who underwent sleeve gastrectomy from 2013 to 2015. Patients with previous bariatric procedures were excluded. Narrowing of a gastric sleeve includes: inability to pass a 9.6 mm gastroscope due to stenosis or sharp angulation or spiral hindering its passage.

Results: Of 400 consecutive patients, 352 are included; the prevalence of dysphagia is 22.7%; 33 patients (9.3%) have narrowing of the sleeve with 25 (7.1%) having sharp angulation or a spiral while 8 (2.3%) have a stenosis. All 33 patients underwent balloon dilatation of the gastric sleeve and dysphagia resolved in 13 patients (39%); 10 patients (30%) noted resolution of dysphagia after two additional dilatations. In a multivariate model, medical conditions associated with post-operative dysphagia include diabetes mellitus, symptoms of esophageal reflux, a low whole blood thiamine level, hypothyroidism, use of non-steroidal anti-inflammatory drugs, and use of opioids.

Conclusion: Narrowing of the gastric sleeve and gastric sleeve stenosis are common after VSG. Endoscopic balloon dilatations of the gastric sleeve resolves dysphagia in 69% of patients.
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http://dx.doi.org/10.3748/wjg.v22.i47.10371DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5175249PMC
December 2016

Diet and Activity Programs Are Ineffective in Nonalcoholic Steatohepatitis.

Mayo Clin Proc 2016 05;91(5):683-4

MedStar-Georgetown Transplant Institute and Georgetown University School of Medicine, Washington, DC.

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http://dx.doi.org/10.1016/j.mayocp.2016.02.021DOI Listing
May 2016

Breath Hydrogen as a Biomarker for Glucose Malabsorption after Roux-en-Y Gastric Bypass Surgery.

Dis Markers 2015 11;2015:102760. Epub 2015 Oct 11.

Department of Surgery and Center for Advanced Laparoscopic & Bariatric Surgery, MedStar-Washington Hospital Center and Georgetown University School of Medicine, Washington, DC 20010, USA.

Objective: Abdominal symptoms are common after bariatric surgery, and these individuals commonly have upper gut bacterial overgrowth, a known cause of malabsorption. Breath hydrogen determination after oral glucose is a safe and inexpensive test for malabsorption. This study is designed to investigate breath hydrogen levels after oral glucose in symptomatic individuals who had undergone Roux-en-Y gastric bypass surgery.

Methods: This is a retrospective study of individuals (n = 63; 60 females; 3 males; mean age 49 years) who had gastric bypass surgery and then glucose breath testing to evaluate abdominal symptoms.

Results: Among 63 postoperative individuals, 51 (81%) had a late rise (≥45 minutes) in breath hydrogen or methane, supporting glucose malabsorption; 46 (90%) of these 51 subjects also had an early rise (≤30 minutes) in breath hydrogen or methane supporting upper gut bacterial overgrowth. Glucose malabsorption was more frequent in subjects with upper gut bacterial overgrowth compared to subjects with no evidence for bacterial overgrowth (P < 0.001).

Conclusion: These data support the presence of intestinal glucose malabsorption associated with upper gut bacterial overgrowth in individuals with abdominal symptoms after gastric bypass surgery. Breath hydrogen testing after oral glucose should be considered to evaluate potential malabsorption in symptomatic, postoperative individuals.
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http://dx.doi.org/10.1155/2015/102760DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4619887PMC
July 2016

Development of minimally invasive techniques for management of medically-complicated obesity.

World J Gastroenterol 2014 Oct;20(37):13424-45

Farzin Rashti, Ekta Gupta, Suzan Ebrahimi, Timothy R Koch, Section of Gastroenterology and Hepatology, MedStar-Washington Hospital Center and Georgetown University School of Medicine, Washington, DC 20010, United States.

The field of bariatric surgery has been rapidly growing and evolving over the past several decades. During the period that obesity has become a worldwide epidemic, new interventions have been developed to combat this complex disorder. The development of new laparoscopic and minimally invasive treatments for medically-complicated obesity has made it essential that gastrointestinal physicians obtain a thorough understanding of past developments and possible future directions in bariatrics. New laparoscopic advancements provide patients and practitioners with a variety of options that have an improved safety profile and better efficacy without open, invasive surgery. The mechanisms of weight loss after bariatric surgery are complex and may in part be related to altered release of regulatory peptide hormones from the gut. Endoscopic techniques designed to mimic the effects of bariatric surgery and endolumenal interventions performed entirely through the gastrointestinal tract offer potential advantages. Several of these new techniques have demonstrated promising, preliminary results. We outline herein historical and current trends in the development of bariatric surgery and its transition to safer and more minimally invasive procedures designed to induce weight loss.
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http://dx.doi.org/10.3748/wjg.v20.i37.13424DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4188895PMC
October 2014

Constipation in patients with thiamine deficiency after Roux-en-Y gastric bypass surgery.

Digestion 2013 20;88(2):119-24. Epub 2013 Aug 20.

Section of Gastroenterology, Department of Medicine, MedStar-Washington Hospital Center and Georgetown University School of Medicine, Washington, D.C., USA.

Background/aims: Roux-en-Y gastric bypass surgery is the most common bariatric surgery worldwide. We have described thiamine deficiency in patients with small intestinal bacterial overgrowth after gastric bypass. We hypothesized that symptoms of thiamine deficiency are common after gastric bypass. The aims of this study were to examine the prevalence of and treatment of symptoms of thiamine deficiency after gastric bypass.

Methods: This is a prospective study performed in a large urban, community hospital. Consecutive gastric bypass patients seen from February 1, 2008 to May 1, 2009 are included. Thiamine deficiency in this study included both: consistent clinical symptoms and either (1) low blood thiamine level or (2) resolution of clinical symptoms after receiving thiamine.

Results: Of 151 patients, 25 females and 2 males met the criteria for thiamine deficiency (prevalence of 18%). In these 27 patients, 12 had one symptom of thiamine deficiency, while 15 had symptoms consistent with multiple subtypes. Eleven patients reported constipation at 0.33-12 years (mean 4.8) after gastric bypass. Elevated serum folate levels were seen in 6 of 10 tested patients and there was an abnormal glucose-hydrogen breath test in 9 of 10 tested patients, supporting the presence of small intestinal bacterial overgrowth. Frequency of defecation improved after thiamine treatment.

Conclusion: Thiamine deficiency resulting from small intestinal bacterial overgrowth should be considered in patients being seen for constipation after gastric bypass surgery.
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http://dx.doi.org/10.1159/000353245DOI Listing
April 2014

Nutritional deficiencies after bariatric surgery.

Nat Rev Endocrinol 2012 Sep 24;8(9):544-56. Epub 2012 Apr 24.

Department of Medicine, Washington Hospital Center, POB North, Suite 3400, 106 Irving Street Northwest, Washington, DC 20010, USA.

Lifestyle intervention programmes often produce insufficient weight loss and poor weight loss maintenance. As a result, an increasing number of patients with obesity and related comorbidities undergo bariatric surgery, which includes approaches such as the adjustable gastric band or the 'divided' Roux-en-Y gastric bypass (RYGB). This Review summarizes the current knowledge on nutrient deficiencies that can develop after bariatric surgery and highlights follow-up and treatment options for bariatric surgery patients who develop a micronutrient deficiency. The major macronutrient deficiency after bariatric surgery is protein malnutrition. Deficiencies in micronutrients, which include trace elements, essential minerals, and water-soluble and fat-soluble vitamins, are common before bariatric surgery and often persist postoperatively, despite universal recommendations on multivitamin and mineral supplements. Other disorders, including small intestinal bacterial overgrowth, can promote micronutrient deficiencies, especially in patients with diabetes mellitus. Recognition of the clinical presentations of micronutrient deficiencies is important, both to enable early intervention and to minimize long-term adverse effects. A major clinical concern is the relationship between vitamin D deficiency and the development of metabolic bone diseases, such as osteoporosis or osteomalacia; metabolic bone diseases may explain the increased risk of hip fracture in patients after RYGB. Further studies are required to determine the optimal levels of nutrient supplementation and whether postoperative laboratory monitoring effectively detects nutrient deficiencies. In the absence of such data, clinicians should inquire about and treat symptoms that suggest nutrient deficiencies.
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http://dx.doi.org/10.1038/nrendo.2012.48DOI Listing
September 2012

Origins of and recognition of micronutrient deficiencies after gastric bypass surgery.

Curr Diab Rep 2011 Apr;11(2):136-41

Section of Gastroenterology, Washington Hospital Center, Washington, DC 20010, USA.

Roux-en-Y gastric bypass surgery remains the major surgical option for individuals with medically complicated obesity. The importance of preoperative evaluation to permit identification of micronutrient deficiencies is being re-evaluated. The risk of complications related to pregnancy after gastric bypass supports careful follow-up. Micronutrient deficiencies are common in postoperative gastric bypass patients, despite the suggested use of routine vitamin and mineral supplements after surgery. Copper deficiency must be considered as an origin for visual disorders after gastric bypass. Vitamin D deficiency with metabolic bone disease remains common after gastric bypass and the results suggest that the present postoperative supplements of calcium and vitamin D are inadequate. Major nutritional complications of bariatric surgery are occurring more than 20 years after surgery. There is no evidence for intestinal adaptation as there remains decreased intestinal absorption of iron up to 18 months after gastric bypass surgery. This article supports ongoing examination of nutritional complications after gastric bypass surgery and supports the notion that the daily doses of micronutrient supplements, such as vitamin D, may need to be revised.
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http://dx.doi.org/10.1007/s11892-010-0169-4DOI Listing
April 2011

Managing medical and surgical disorders after divided Roux-en-Y gastric bypass surgery.

Nat Rev Gastroenterol Hepatol 2010 Jun 11;7(6):320-34. Epub 2010 May 11.

Section of Gastroenterology, Washington Hospital Center and Georgetown University School of Medicine, Washington, DC 20010, USA.

The National Longitudinal Study of Adolescent Health and the National Health and Nutrition Examination Survey reported that over 40% of the US population is overweight. The average weight loss attained by medical management programs is neither sufficient nor durable enough to treat medically complicated obesity. An estimated 220,000 bariatric procedures are performed yearly in the USA and Canada. The divided Roux-en-Y gastric bypass (RYGB) is performed most commonly in these countries and is considered the gold standard bariatric surgical procedure. The complexity of RYGB means that serious and potentially preventable perioperative complications can occur. RYGB alters the normal anatomy and physiology of the upper gut, which has predictable adverse effects and potential complications. Patients seek advice and care for symptoms that develop or persist after RYGB; although some symptoms are expected and predictable, others are complications that may or may not require active medical or surgical intervention. Physicians should be able to predict and manage most postoperative medical and nutritional disorders related to RYGB and should be prepared to assess patients for potential referral for surgical intervention or revision.
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http://dx.doi.org/10.1038/nrgastro.2010.60DOI Listing
June 2010

Postoperative metabolic and nutritional complications of bariatric surgery.

Gastroenterol Clin North Am 2010 Mar;39(1):109-24

Georgetown University School of Medicine, 3900 Reservoir Road NW, Washington, DC 20057, USA.

Bariatric surgery has become an increasingly important method for management of medically complicated obesity. In patients who have undergone bariatric surgery, up to 87% with type 2 diabetes mellitus develop improvement or resolution of their disease postoperatively. Bariatric surgery can reduce the number of absorbed calories through performance of either a restrictive or a malabsorptive procedure. Patients who have undergone bariatric surgery require indefinite, regular follow-up care by physicians who need to follow laboratory parameters of macronutrient as well as micronutrient malnutrition. Physicians who care for patients after bariatric surgery need to be familiar with common postoperative syndromes that result from specific nutrient deficiencies.
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http://dx.doi.org/10.1016/j.gtc.2009.12.003DOI Listing
March 2010

Small intestinal bacterial overgrowth and thiamine deficiency after Roux-en-Y gastric bypass surgery in obese patients.

Nutr Res 2008 May;28(5):293-8

Department of Medicine, Washington Hospital Center, Washington, DC 20010-2975, USA.

It has been proposed that thiamine deficiency after gastric bypass surgery in obese patients results from prolonged nausea and emesis. We hypothesized that thiamine deficiency is induced by altered gut ecology. This report includes 2 retrospective studies of obese patients who underwent Roux-en-Y gastric bypass surgery at our institution from 1999 to 2005. In the first study, 80 patients (52 women and 28 men) had measurement of whole-blood thiamine diphosphate level and serum folate level. In these 80 patients, 39 (49%) had thiamine diphosphate levels less than the lower limit of the reference range, and 28 (72%) of the 39 had folate levels higher than the upper limit of the reference range, an indicator of small intestinal bacterial overgrowth. In 41 patients with normal thiamine levels, only 14 (34%) had folate levels higher than the upper limit of the reference range (chi(2) test, P < .01). In the second study, 21 patients (17 women and 4 men) had thiamine diphosphate levels less than the lower limit of the reference range and abnormal glucose-hydrogen breath tests, consistent with small intestinal bacterial overgrowth. Fifteen patients received oral thiamine supplements, but repeated thiamine levels remained low in all 15. Nine of these patients then received oral antibiotic therapy; repeated thiamine levels were found to be normal in all 9 patients. These results support the hypothesis that small intestinal bacterial overgrowth results from altered gut ecology and induces thiamine deficiency after gastric bypass surgery in obese patients.
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http://dx.doi.org/10.1016/j.nutres.2008.03.002DOI Listing
May 2008

Chronic gastrointestinal symptoms of Thomas "Stonewall" Jackson following Mexican-American War exposure: a medical hypothesis.

Mil Med 2007 Jan;172(1):6-8

Section of Gastroenterology, Washington Hospital Center and Georgetown University School of Medicine, 110 Irving Street, NW, Washington, DC 20010, USA.

In a recent study, a large proportion of veterans seen for chronic heartburn or dyspepsia after the Persian Gulf War had evidence for Helicobacter pylori. Thomas Jackson was born and raised in an area of West Virginia that has a high prevalence of H. pylori. He suffered chronic dyspeptic symptoms following his service in the Mexican-American War. Therapies that he tried included treatment with a variant of the Sippy diet. Following a bullet wound to the left arm at the battle of Chancellorsville on Saturday, May 2, 1863, Thomas Jackson underwent amputation of the left arm below the left shoulder. He died 1 week later with a diagnosis of pleuropneumonia. The records of the postsurgical course are incomplete. The available clinical information raises the hypothesis that his chronic dyspepsia and his cause of death could have been related to chronic peptic ulcer disease due to gastric H. pylori infection.
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http://dx.doi.org/10.7205/milmed.172.1.6DOI Listing
January 2007

Micronutrient supplements in inflammatory bowel disease.

Dis Mon 2006 May;52(5):211-20

Section of Gastroenterology, Washington Hospital Center, Georgetown University School of Medicine, Washington, DC, USA.

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http://dx.doi.org/10.1016/j.disamonth.2006.05.008DOI Listing
May 2006

Mechanisms of micronutrient deficiency.

Dis Mon 2006 May;52(5):208-10

Section of Gastroenterology, Washington Hospital Center, Georgetown University School of Medicine, Washington, DC, USA.

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http://dx.doi.org/10.1016/j.disamonth.2006.05.006DOI Listing
May 2006

Oxidative stress and antioxidants in inflammatory bowel disease.

Dis Mon 2006 May;52(5):199-207

Section of Gastroenterology, Washington Hospital Center, Georgetown University School of Medicine, Washington, DC, USA.

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http://dx.doi.org/10.1016/j.disamonth.2006.05.005DOI Listing
May 2006

Nutrition in inflammatory bowel disease, part I: summary.

Authors:
Timothy R Koch

Dis Mon 2006 Apr;52(4):176

Section of Gastroenterology, Washington Hospital Center, Georgetown University School of Medicine, Washington, DC, USA.

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http://dx.doi.org/10.1016/j.disamonth.2006.05.011DOI Listing
April 2006

Nutrient supplements in inflammatory bowel disease.

Dis Mon 2006 Apr;52(4):170-5

Section of Gastroenterology, Washington Hospital Center, Georgetown University School of Medicine, Washington, DC, USA.

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http://dx.doi.org/10.1016/j.disamonth.2006.05.007DOI Listing
April 2006

Mechanisms of macronutrient deficiency and associated clinical conditions.

Dis Mon 2006 Apr;52(4):164-9

Section of Gastroenterology, Washington Hospital Center, Georgetown University School of Medicine, Washington, DC, USA.

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http://dx.doi.org/10.1016/j.disamonth.2006.05.004DOI Listing
April 2006

Nutrition in inflammatory bowel disease, part I: introduction.

Dis Mon 2006 Apr;52(4):149-50

The Joseph B. Kirsner Center for the Study of Digestive Diseases, The University of Chicago, Illinois, USA.

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http://dx.doi.org/10.1016/j.disamonth.2006.05.001DOI Listing
April 2006

Narcotic use in patients with Crohn's disease.

Am J Gastroenterol 2006 Jun;101(6):1397; author reply 1397-8

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http://dx.doi.org/10.1111/j.1572-0241.2006.00595_3.xDOI Listing
June 2006

Evaluation of chronic gastrointestinal symptoms following Persian Gulf War exposure.

Mil Med 2005 Aug;170(8):696-700

Lewis A Johnson Veterans Affairs Medical Center, West Virginia University, Morgantown, WV, USA.

This was a prospective study performed in a Department of Veterans Affairs Medical Center. The aim of this study was to use endoscopic and histological examinations to determine the potential diagnostic origins of chronic gastrointestinal symptoms among patients who were part of the deployment of troops to the Persian Gulf after August 1990. Twenty-four (8%) male patients (mean age, 42 years) of 308 patients in the Persian Gulf War Registry agreed to undergo endoscopic examination of chronic symptoms, including heartburn (29%), dyspepsia (33%), dysphagia (8%), diarrhea (63%), Hemoccult-positive stool (21%), and rectal bleeding (17%). There were 17 upper endoscopies, 18 colonoscopies, and 4 flexible sigmoidoscopies performed, all with biopsies. Five (33%) of 15 patients had positive serological findings for Helicobacter pylori. With upper endoscopy, major findings included esophagitis (12%), Schatzki's ring (12%), hiatal hernia (47%), antral erythema (59%), and duodenal erythema (29%). With lower endoscopy, major findings included ileitis (5%), lymphoid hyperplasia (9%), polyps (27%), diverticulosis (23%), and hemorrhoids (23%). Major histopathological findings included microscopic esophagitis (24%), gastritis with H. pylori (35%), gastritis without H. pylori (18%), Crohn's disease (5%), tubular adenoma (5%), hyperplastic polyps (18%), and melanosis coli (5%). Most patients with chronic heartburn or dyspepsia have evidence of esophagitis or H. pylori. Individuals with these chronic symptoms should undergo evaluation.
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http://dx.doi.org/10.7205/milmed.170.8.696DOI Listing
August 2005

Multifocal gastric carcinoid tumor in a patient with pernicious anemia receiving lansoprazole.

Dig Dis Sci 2005 Mar;50(3):509-13

Division of Gastroenterology & Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA.

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http://dx.doi.org/10.1007/s10620-005-2466-3DOI Listing
March 2005

Effects of esomeprazole magnesium on nonsteroidal anti-inflammatory drug gastropathy.

Dig Dis Sci 2005 Jan;50(1):86-93

Division of Gastroenterology & Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin 53295, USA.

It has been proposed that tissue damage induced by nonsteroidal anti-inflammatory drugs is related to increased tissue free radical production with antioxidant depletion. We have shown that esomeprazole increases gastric total antioxidant capacity in mice and, therefore, hypothesized that the protective effect of esomeprazole during treatment with a nonsteroidal anti-inflammatory drug is related to increased gastric antioxidant capacity and decreased tissue free radical production. A/J mice received one of four treatments by daily gavage: saline in vehicle (control), indomethacin, esomeprazole, or indomethacin and esomeprazole. After 10 days, all mice were sacrificed and validated assays were used to measure gastric total antioxidant capacity, lipid peroxide levels, and myeloperoxidase activity. Indomethacin-treated mice developed weight loss and melena. No mice receiving indomethacin and esomeprazole died, but the death rate while receiving indomethacin was 38% (chi2, P = 0.05). Gastric lipid peroxide levels increased in mice receiving indomethacin treatment compared to treatment with esomeprazole and indomethacin (P = 0.03). There was a strong trend (P = 0.08) toward increased gastric total antioxidant capacity in mice receiving esomeprazole and indomethacin compared to mice receiving indomethacin. Gastric myeloperoxidase activities were not different among the four groups. Esomeprazole significantly improved survival in mice that received indomethacin, reduced free radical production, as estimated by lipid peroxide levels, and appeared to increase gastric total antioxidant capacity. The mechanisms for the beneficial effects of esomeprazole in the treatment of gastropathy are more complex than previously thought.
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http://dx.doi.org/10.1007/s10620-005-1283-zDOI Listing
January 2005

Oxidative stress in nonalcoholic fatty liver disease: pathogenesis and antioxidant therapies.

J Investig Med 2004 Dec;52(8):506-14

Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA.

Nonalcoholic fatty liver disease is a common cause of chronic liver disease, a common finding on liver biopsy in those patients with abnormal blood transaminase levels, and a common cause of cryptogenic cirrhosis in the United States. The prevalence of this disorder is expected to rise with the increase in obesity, and the clinical spectrum can range from simple steatosis (fatty liver) to cirrhosis of the liver. Insulin resistance is thought to be pivotal for the development of steatosis, and oxidative stress may be a potential factor that can promote hepatic necroinflammation and fibrosis. Preliminary studies have examined the role of oxidative stress and antioxidants in animal and human studies of this disorder. Efforts to improve the hepatic antioxidant system could be achieved by optimizing the patient's diet, by supplementation with precursors for antioxidants, or by supplementation with essential metals and/or antioxidants. Randomized, controlled trials are required to examine these potential approaches using patients with this disorder.
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http://dx.doi.org/10.1136/jim-52-08-22DOI Listing
December 2004

Effect of the H, K-ATPase inhibitor, esomeprazole magnesium, on gut total antioxidant capacity in mice.

J Nutr Biochem 2004 Sep;15(9):522-6

Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 9200 West Wisconsin Ave., Milwaukee, WI 53295, USA.

Antioxidant depletion is believed to be a mechanism involved in the pathophysiology of several upper gastrointestinal disorders, and H, K-ATPase inhibitors can alter free radical production by neutrophils. We hypothesized that the H, K-ATPase inhibitor esomeprazole magnesium would decrease gut free radical production with a concomitant increase in gut total antioxidant capacity. A/J mice (n = 10/group) received either vehicle (control) or one of three concentrations of esomeprazole magnesium in vehicle by once-daily gavage for 10 days. Using tissue extracts from stomach and colon, total antioxidant capacity, lipid peroxide levels, and constitutive Cu/Zn-superoxide dismutase were measured using validated assays. There was a dose-related increase in total antioxidant capacity (analysis of variance, P < 0.001) in stomach, but there was no change in the colon. In the assessment of free radical production, there was a trend toward decreased lipid peroxide levels in stomach from mice receiving esomeprazole. In stomach, Cu/Zn-superoxide dismutase activity was increased (ANOVA: p=.03) in mice receiving esomeprazole. In conclusion, gastric total antioxidant capacity and Cu/Zn-superoxide dismutase activity are increased by esomeprazole, and these changes may result in part from decreased free radical production. The present results support the notion that the pharmacological effects of this agent on upper intestinal tissue are more complex than previously thought, and appear to involve both enzymatic and nonenzymatic tissue antioxidants.
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http://dx.doi.org/10.1016/j.jnutbio.2004.03.003DOI Listing
September 2004