Post Op Iron Deficiency: From Nuisance to Nasty



From The Savvy Sister

When we have a discussion about complications after Bariatric Surgery, we usually speak of the "big ones" (PE, death, DVT, staple line leak, bleeding, Infection, obstruction, Hernia...).

Much more prevalent, and usually of a nuisance character, are the micronutrient deficiencies.  These most typically occur after malabsorptive surgeries (Gastric Bypass, also Duodenal Switch), but can occur with restrictive procedures as well (Gastric Band and Sleeve Gastrectomy).

With the former, nutrient absorption is altered or significantly diminished by "bypassing" the anatomical sites where absorption is physiologically preferred.  With the restrictive surgeries, nutrient absorption remains essentially unaffected, but due to significantly less nutritional intake and perhaps maladaptive eating styles post-surgery, the same can result.

We do check a full panel of labs on our new patients, and often find a number of pre-existent abnormalities on the nutritional side.  It is not uncommon to see depressed Vitamin D levels, low Fe, as well as a mild to moderate microcytic anemia from Fe deficiency.  Of note, our patient population is about 75% female, and most in their child bearing years.


Post op, we start checking labs at 3 mos, unless indicated earlier.  As far as Fe goes, we check Fe level / TIBC/Ferritin/and %Fe Saturation along with a CBC.  We can occasionally start seeing some deficiency developing 6 mos or so after surgery, despite a regular supplemental schedule with vitamins and minerals.  Compliance with the vitamin regimen is not uncommonly an issue, and is the first-line of treatment if  levels are low.  We have patients take a bariatric all-inclusive vitamin (Fusion) 4x per day, or our standard mix of vitamins is as follows:

   *Multivitamin with Fe daily
   *B12 1,000 mcg daily
   *B Complex Daily
   *Calcium Citrate 500 with D BID

If we need additional Fe, we use OTC Ferrous Sulfate 325, preferrably BID, with some vitamin C to enhance absorption.  Should a patient either not respond to, or be GI intolerant with the PO form and have deteriorating Fe stores, a Hematology consult is warranted for IV Fe.

A review of the symptoms goes along with what you would think you would see with Fe deficiency / anemia, with fatigue, new DOE, palpitations, pica / pagophagia (chewing on ice), sometimes vague abdominal pain, headaches, malaise, weakness, even syncope, etc.  These are a myriad of  vague compaints, actually, that as isolated complaints could be easily overlooked, but put in context of a post op weight loss patient, definitely need a further evaluation. 

And, as per the previous post on Follow up, we do check our post op panel every 3 mos for the first year to detect a nutritional issue early, or evaluate current treatment status of a previously treated one.