Post biliopancreatic bypass arthritis. Dermatitis
syndrome.
Cantatore FP, Carrozzo M, Loperfido MC
Department of Rheumatology, University of
Bari, Italy.
A case of arthritis dermatitis syndrome
observed after a biliopancreatic bypass for morbid obesity is described.
The syndrome had begun 10 days after surgery and involved the knees,
ankles, elbows and wrists and erythema nodosum on the legs. After 15
days treatment with sulfasalazine and steroid the symptoms disappeared.
The immunologic aetiology of the disease was postulated and the
observation of the syndrome, for the first time, after a biliopancreatic
bypass suggested that the manifestation of the disease is independent of
the kind of the surgical procedures used for the treatment of the morbid
obesity.
PMID: 1686994, UI: 92200811
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Dig Dis Sci 1990 May;35(5):656-60
Cure of arthritis-dermatitis syndrome due to
intestinal bypass by resection of nonfunctional segment of blind loop.
Drenick EJ, Roslyn JJ
Medical and Research Service, Wadsworth VA
Medical Center, Los Angeles, California 90073.
Many complications that followed
jejunoileal bypass operations performed for the relief of morbid obesity
were caused by bacterial overgrowth in the excluded blind loop. The
arthritis-dermatitis syndrome was one of the common distressing
disorders. The pathogenetic mechanism was thought to be an
immune-complex-mediated process related to bypass enteritis.
Antiarthritic medication was ineffective in most instances, and the skin
lesions were refractory to treatment. A 45-year-old woman was suffering
from the disorder as described above. She also had diarrhea, a low
hematocrit, an elevated white blood cell count, and an increased
sedimentation rate. Her nutritional status was satisfactory, presumably
because of adaptive hypertrophy of the short functioning small
intestinal segment. The patient adamantly refused dismantling of the
bypass or any gastric restriction operations. Therefore, the blind loop,
the source of her disease, was excised with immediate relief of all ill
effects and restoration of normal laboratory findings. The patient has
been entirely well since, and her weight has remained stable for one
year.
PMID: 2331958, UI: 90235725
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Baillieres Clin Rheumatol 1989
Aug;3(2):339-55
Jejunoileal bypass arthritis.
Ross CB, Scott HW, Pincus T
Although intestinal bypass procedures are
no longer performed, important lessons have been learned concerning
clinical arthritides resulting from bacterial overgrowth and immune
complex deposition. This information is of considerable value in
patients who present with the clinical picture of intestinal bypass
arthritis on the basis of other bowel abnormalities. Furthermore, the
pathogenetic mechanisms involving bacterial overgrowth, release of
bacterial antigens, and immune complex deposition may be pertinent to
many types of inflammatory arthritis.
Publication Types:
Review
Review, tutorial
PMID: 2670259, UI: 89354621
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Clin Exp Rheumatol 1987
Jul-Sep;5(3):275-87
Bypass disease.
Clarke J, Weiner SR, Bassett LW, Utsinger PD
Department of Rheumatology, Mount Sinai
Hospital, Medical Center, Chicago, Illinois.
Intestinal bypass surgery as a treatment
for morbid obesity was quite popular from 1965 to 1975 in the United
States. The procedure was successful in reducing body weight but was
controversial because of a high rate of complications which included an
arthritis-dermatitis syndrome. Herein we review the knowledge garnered
from a study of the complications from intestinal bypass surgery.
Emphasis is placed on an analysis of the clinical manifestations, and
the pathogenesis of the arthritis-dermatitis bypass syndrome, and how
bypass disease may serve as a model for immune complex-mediated disease
and for extra-intestinal complications in other enteropathies.
Publication Types:
Review
Review, academic
PMID: 3322621, UI: 88110135
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Tidsskr Nor Laegeforen 1986 Dec
10;106(34-36):2984
[Intestinal bypass dermatitis-arthritis syndrome. A
rare complication in the surgical treatment of obesity].
In a recent report we described a syndrome,
identical to bowel-bypass syndrome, that occurred in four patients who
had not had bypass surgery. Herein, circulating immune complexes (CICs)
and neutrophil migration are evaluated in three of those four patients
to test the hypothesis that the cutaneous lesions might have resulted
from interaction between immune complex-mediated vessel damage and
increased neutrophil migration. In vitro assays indicated that CICs were
present in one of two patients and "histamine trap" test
evidence for CICs was present in both patients tested. Although serum
from the three patients appeared to increase neutrophil movement,
statistically significant increases were not observed when data were
pooled in this small study group. Preliminary results suggest that
immune complex-mediated vessel damage, followed by extensive
accumulation of neutrophils, may cause the pustular vasculitis in the
bowel-associated dermatosis-arthritis syndrome.
PMID: 6712372, UI: 84177692
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Rev Infect Dis 1984 Mar-Apr;6
Suppl 1:S80-4
Jejunoileal bypass: change in the flora of the small
intestine and its clinical impact.
Corrodi P
Among the complications of jejunoileal
bypass for morbid obesity are proctitis, bypass enteritis, liver
disease, dermatitis, and arthritis, all of which are thought to be
connected with the intestinal microflora. Quantitative cultures from the
small bowel of patients before the establishment of the bypass and from
patients with reoperations indicate colonization of both the functioning
small bowel (bacterial counts, 10(5.0)-10(7.6)/ml) and of the bypassed
loop (bacterial counts, 10(6.4)-10(9.7)/ml). Experiments in animals have
shown that the presence of a bypassed loop, as compared with that of a
resected bowel, is necessary for increased weight loss and for the
development of liver disease. Clinical evidence for the impact of the
intestinal microflora is based on the beneficial effect of antimicrobial
agents, especially metronidazole, and on the demonstration of
immunologic phenomena involving antigens of bacterial origin.
Complications of jejunoileal bypass may serve to elucidate the
pathogenesis of other diseases.
Publication Types:
Review
PMID: 6372041, UI: 84195884
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Acta Derm Venereol
1984;64(1):79-82
Bowel bypass arthritis dermatitis syndrome: a
histological and electron microscopical study.
Sandbank M, Weltfriend S, Wolf R
A case of dermal vasculitis with arthralgia
after intestinal bypass surgery is reported. A 36-year-old woman
developed arthralgia and skin rash, 1 year after an ileo-jejunal bypass
operation was performed for overweight (130 kg). Skin biopsy showed
leucocytoclastic vasculitis in the dermis. E.M. study showed clumps of
platelets around small dermis blood vessels, and polymorphous
perivascular infiltration. The symptoms subsided after tetracycline
treatment.
PMID: 6203290, UI: 84226885
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J Rheumatol 1983 Aug;10(4):612-8
A prospective analysis of the arthritis syndrome and
immune function in jejunoileal bypass patients.
Leff RD, Towles W, Aldo-Benson MA, Madura J, Biegel
AA
Fifty-two patients undergoing jejunoileal
bypass surgery were prospectively evaluated to determine: 1) the
incidence of the associated arthritic syndrome; 2) whether we could
identify patients at risk for arthritis prior to surgery; and 3) changes
in immune function. The incidence of arthritis was 28% and was
frequently associated with dermatitis. No preoperative clinical or
laboratory parameters identified those patients at risk to develop
rheumatic problems. Circulating immune complexes were found in both
arthritis and non-arthritis patients after surgery. Mean serum levels of
IgA rose significantly after surgery only in patients who developed
arthritis, but remained within the normal range. No other immunologic
abnormalities were noted.
PMID: 6620263, UI: 84010661
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Scand J Rheumatol 1983;12(3):257-9
Episodic arthritis, skin manifestations and immune
complexes following intestinal by-pass operations for morbid obesity.
Heyn J, Hey H, Jans H, Baek L, Ullman S, Halberg P
A systematic search for immune complexes
(IC) in blood and skin revealed no correlation to IC-related disorders
in 35 patients who had undergone jejunoileal bypass for obesity. Tests
for cryoprecipitates and endotoxins proved negative.
PMID: 6623014, UI: 84017453
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Arthritis Rheum 1981
May;24(5):684-90
The intestinal bypass: arthritis-dermatitis syndrome.
Stein HB, Schlappner OL, Boyko W, Gourlay RH, Reeve
CE
Of the 31 patients who developed
polyarthritis following jejunoileal bypass for obesity, 24 had cutaneous
vasculitis (urticarial, pustular, and nodular), 11 paresthesias, 10
Raynaud's phenomenon, and 1 pericarditis. Blind loop symptoms (14 of 26
patients), cryoglobulinemia (10 of 28), and immune deposits in biopsied
skin lesions (5 of 7) support the theory of a relationship between bowel
bacteria and immune complexes. Treating the blind loop with antibiotics
and sphincteroplasty to prevent bacterial reflux into the blind loop
helped 5 of 10 and 6 of 9 patients, respectively. A comparison is made
to other bowel associated arthritides.
PMID: 7236324, UI: 81207373
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J Am Acad Dermatol 1980
Jun;2(6):488-95
Systemic immune complex disease following intestinal
bypass surgery: bypass disease.
Utsinger PD
Twenty-one patients with arthritis and
dermatitis following intestinal bypass surgery were studied. The
arthritis was polyarticular, remittent, and intermittent. Typically, the
synovial fluid was inflammatory. The commonest inflammatory skin lesion
was a vesiculopustular dermatitis. Nineteen patients and serum immmune
complexes using the Raji cell technic. Seventeen patients had serum
cryoproteins, primarily consisting of IgG 1, IgG 3, C3, and C4. Three
patients had both Escherichia coli antigens and anti-E. coli antibody in
their cryoprotein. Five patients had granular and one had linear
deposits of immunoglobulin and complement at the dermoepidermal
junction. Further evidence that bacterial antigens play a role in tissue
injury was provided by detection of granular deposits of E. coli antigen
at the dermoepidermal junctions in two patients, and at the glomerular
capillary basement membrane in one patient.
PMID: 6447168, UI: 80250045
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Hosp Pract 1977 Jan;12(1):73-82
Ileal bypass for obesity: postoperative perspective.
Faloon WW
Initially, diarrhea is almost universal but
becomes self-limited unless the patient persists in overeating. Weight
loss averages 75 to 100 lb the first year, with a stable level generally
achieved after 18 months. Among the serious potential complications are
enteritis, kidney stones, gallstones, and hepatopathology. Some can be
anticipated and kept at bay by prophylactic measures like high-protein
intake.
PMID: 838488, UI: 77117544
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Am J Clin Nutr 1977
Jan;30(1):76-89
Bypass enteropathy: an inflammatory process in the
excluded segment with systemic complications.
Drenick EJ, Ament ME, Finegold SM, Passaro E Jr
Evidence is presented that many of the
enteric and systemic manifestations after jejunoileal bypass can be
related to an inflammatory process within the bypassed small bowel
rather than to the surgically induced sequelae of a short bowel syndrome
with malabsorption. Invasion of the excluded segment by fecal flora was
associated with a histologically demonstrable inflammatory response of
the mucosa. The disorder was of variable severity and duration and
occurred in the majority of 28 bypass patients. Progression to a
clinical syndrome resembling an acute abdomen occurred in about 15% of
the patients. Small bowel ileus and, in some patients, obstruction of
the colon were suggested by physical signs and x-ray findings. Surgical
exploration in such instances demonstrated an inflammaotry process of
the excluded small bowel loops with severe distention of this segment
and of the colon, but not organic obstruction. Pneumatosis cystoides
intestinalis was a sequal in two patients. Exudative protein loss was
documented in the severe cases. Most of the systemic sequelae are
comparable to those seen with inflammatory diseases of the bowel such as
Crohn's disease. Fever, excessive weight and lean tissue loss, and the
involvement of skin, blood vessels, joints and possibly, the liver
suggest an immune response as a common factor in the pathogenesis. The
clinical improvement with antibiotics such as metronidazole or with
restitution of normal bowel continuity indicates that the bacterial
flora in the excluded small bowel segment or its byproducts are causally
related to the systemic complications. Hyperoxaluria may be primarily
the sequela of steatorrhea and not of the inflammatory process.
PMID: 831442, UI: 77084961
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Warning:
Gastric Bypass Surgery is a MAJOR surgical procedure. It
can be associated with significant
risks and complications, up to and including death.Weight loss surgery is a rapidly developing area of medicine.
Bariatric surgery is filled withcontroversy. It
is very important to take a careful and deliberate approach to considering
surgery for the treatment of obesity.
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