A 56-year-old man comes to the emergency department because of sudden onset of severe, diffuse abdominal pain. The patient has experienced 3 months of epigastric pain that has been refractive to proton-pump inhibitor therapy. Physical examination reveals an exquisitely tender, rigid abdomen with rebound tenderness. Abdominal radiographs reveal free air under the diaphragm. Supportive therapy is initiated. Exploratory laparotomy reveals a large, perforated gastric ulcer with features suggestive of malignancy. He undergoes partial gastrectomy with gastrojejunostomy. Long-term supplementation with which of the following is most important in this patient?

Question

A 56-year-old man comes to the emergency department because of sudden onset of severe, diffuse abdominal pain.  The patient has experienced 3 months of epigastric pain that has been refractive to proton-pump inhibitor therapy.  Physical examination reveals an exquisitely tender, rigid abdomen with rebound tenderness.  Abdominal radiographs reveal free air under the diaphragm.  Supportive therapy is initiated.  Exploratory laparotomy reveals a large, perforated gastric ulcer with features suggestive of malignancy.  He undergoes partial gastrectomy with gastrojejunostomy.  Long-term supplementation with which of the following is most important in this patient?

Quizplus · Accepted Answer

11ec160b_3bd2_1dc8_9249_5d37cbd653b9_MD0001_00 Partial gastrectomy with gastrojejunostomy is most often performed to treat complicated peptic ulcer disease (eg, perforation, malignancy, gastric outlet obstruction) or ulcers refractory to medical management. In a Billroth II gastrojejunostomy, the gastric antrum is removed to decrease gastrin production and for histopathologic evaluation. A side-to-side anastomosis is then made between the jejunum and the gastric body, bypassing the duodenum and proximal jejunum. Iron absorption occurs predominantly in the duodenum and proximal jejunum, and bypass of this segment of small bowel results in iron deficiency anemia. The post-surgical decrease in gastric acidity also diminishes iron absorption and may contribute to iron deficiency in these patients. Treatment is accomplished with pharmacologic iron supplementation, which allows for adequate iron absorption at secondary absorption sites in the distal small bowel. Deficiency involving thiamine, folate, vitamin B₁₂, fat-soluble vitamins (especially vitamin D), and calcium is also common following gastrojejunostomy. (Choice A) Although ascorbic acid (vitamin C) can increase the bioavailability of nonheme iron, vitamin C supplementation would not be enough to counteract the effect of decreased iron absorption post-gastrojejunostomy. (Choices B and D) Biotin (vitamin B₇) and pantothenic acid (vitamin B₅) are absorbed in the small and large intestine via the sodium-dependent multivitamin transporter. Deficiency of either of these vitamins is rare and not associated with gastric bypass procedures. (Choice E) Pyridoxine (vitamin B₆) absorption occurs in the jejunum and the ileum by passive diffusion and is not typically affected by gastrojejunostomy. Educational objective: Iron absorption occurs predominantly in the duodenum and proximal jejunum. Bypass of this segment of small bowel by gastrojejunostomy results in iron deficiency anemia that can be corrected with pharmacologic iron supplementation. Malabsorption of thiamine, folate, vitamin B₁₂, fat-soluble vitamins (especially vitamin D), and calcium is also common following gastric bypass procedures.

A 56-Year-Old Man Comes to the Emergency Department Because of Sudden