Introduction: Bariatric surgery is now a common surgical procedure for weight management recommended by NICE. Complications such as dumping syndrome, micronutrient deficiencies and cholelithiasis are well documented in the literature. Here we discuss the lesser reported complication of adrenal insufficiency seen in three patients following roux-en-y gastric bypass surgery for morbid obesity.
Case reports: Three patients were seen in the outpatient clinic post bariatric surgery. Patient A: complained of symptoms suggestive of dumping, nausea, sweating and lethargy. Patient B presented to clinic five years following bariatric surgery complaining of cramps, thinning hair, constipation, lethargy and anxiety. Patient C complained of excessive tiredness a year following surgery. Baseline cortisol was very low in all three patients. All three patients had poor cortisol response following a challenge with synacthen, pituitary function was normal, adrenal antibody was negative and imaging of the pituitary gland did not reveal any abnormality. All three patients were started on hydrocortisone with resulting improvement in their symptoms.
Discussion: The cause of adrenal insufficiency in these cases remains unexplained. Potential mechanisms include disruption to absorption of bile and absorption of vitamins and trace elements affecting steroid synthesis; weight loss causing alteration to the hypothalamo-pituitary-adrenal axis; damage to the pituitary/adrenal glands as a result of stress; blood loss during surgery resulting in pituitary/adrenal insufficiency or reduction in steroid metabolites produced by adipose tissue.
Conclusion: These cases highlight the importance of long-term follow-up of patients post-bariatric surgery and the importance of checking the cortisol level in patients who are symptomatic with dizziness and lethargy. Rapid weight loss which is expected with bariatric surgery may mask symptoms of adrenal insufficiency.