9 https://e-fs.org ABSTRACT Anemia is a common complication aſter gastric cancer and bariatric surgery and significantly influences the patient's postoperative recovery, quality of life, and long-term outcome. This article reviews the common etiopathogenesis of postoperative anemia following gastrointestinal surgery. Keywords: Anemia; Gastrectomy INTRODUCTION Anemia is a common complication aſter gastrointestinal surgery and has a significant influence on the patient's postoperative recovery and the quality of life [1, 2]. Besides, anemia has been reported to increase the risk of malignancies of the gastrointestinal tract. Among the patients who underwent gastrectomy, patients with iron deficiency anemia have 2–3 times increased risk of gastric cancer aſter 20 years, and the risk of colon cancer is also likely to increase. Thus patients who underwent gastrointestinal surgery and older than 50 years of age are advised to perform gastrointestinal evaluations for anemia [3, 4]. Bariatric surgery for morbid obesity is increasing rapidly, and the most common nutritional complication aſter obesity surgery is anemia [5-7]. Therefore, the prevention and management of anemia are important in gastrointestinal surgery patients. However, due to physical and biochemical alterations in the gastrointestinal tract aſter gastrointestinal surgery, the management of anemia may not be effective in surgical patients. Hence, this review aimed to summarize the pathophysiology of anemia in gastrointestinal surgery patients. EPIDEMIOLOGY Postoperative anemia is one of the common complications aſter gastrectomy, and its incidence has been reported in more than 3/4 of patients immediately aſter surgery. The incidence declined over time and improved in about 40% of patients spontaneously three months aſter surgery. However, the remaining patients required proper management for the postoperative anemia [8]. Foregut Surg. 2021 Jan;1(1):9-12 https://doi.org/10.51666/fs.2021.1.e4 pISSN 2765-2890·eISSN 2765-3110 Review Article Received: Jan 27, 2021 Accepted: Jan 27, 2021 Corresponding author: Minah Cho Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea. E-mail: [email protected] Copyright © 2021. The Korean Society of Gastrointestinal Surgery This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https:// creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ORCID iDs Minah Cho https://orcid.org/0000-0003-3011-5813 Funding The author has no financial support to disclose. Conflict of Interest No potential conflict of interest relevant to this article was reported. Minah Cho Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea Etiopathogenesis of anemia in gastrointestinal surgery patients
Etiopathogenesis of anemia in gastrointestinal surgery patients
Nov 06, 2022
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9https://e-fs.org
ABSTRACT
Anemia is a common complication after gastric cancer and bariatric surgery and significantly influences the patient's postoperative recovery, quality of life, and long-term outcome. This article reviews the common etiopathogenesis of postoperative anemia following gastrointestinal surgery.
Keywords: Anemia; Gastrectomy
INTRODUCTION
Anemia is a common complication after gastrointestinal surgery and has a significant influence on the patient's postoperative recovery and the quality of life [1, 2]. Besides, anemia has been reported to increase the risk of malignancies of the gastrointestinal tract. Among the patients who underwent gastrectomy, patients with iron deficiency anemia have 2–3 times increased risk of gastric cancer after 20 years, and the risk of colon cancer is also likely to increase. Thus patients who underwent gastrointestinal surgery and older than 50 years of age are advised to perform gastrointestinal evaluations for anemia [3, 4].
Bariatric surgery for morbid obesity is increasing rapidly, and the most common nutritional complication after obesity surgery is anemia [5-7]. Therefore, the prevention and management of anemia are important in gastrointestinal surgery patients. However, due to physical and biochemical alterations in the gastrointestinal tract after gastrointestinal surgery, the management of anemia may not be effective in surgical patients. Hence, this review aimed to summarize the pathophysiology of anemia in gastrointestinal surgery patients.
EPIDEMIOLOGY
Postoperative anemia is one of the common complications after gastrectomy, and its incidence has been reported in more than 3/4 of patients immediately after surgery. The incidence declined over time and improved in about 40% of patients spontaneously three months after surgery. However, the remaining patients required proper management for the postoperative anemia [8].
Foregut Surg. 2021 Jan;1(1):9-12 https://doi.org/10.51666/fs.2021.1.e4 pISSN 2765-2890·eISSN 2765-3110
Review Article
Received: Jan 27, 2021 Accepted: Jan 27, 2021
Corresponding author: Minah Cho Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea. E-mail: [email protected]
Copyright © 2021. The Korean Society of Gastrointestinal Surgery This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https:// creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
ORCID iDs Minah Cho https://orcid.org/0000-0003-3011-5813
Funding The author has no financial support to disclose.
Conflict of Interest No potential conflict of interest relevant to this article was reported.
Minah Cho
Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
Etiopathogenesis of anemia in gastrointestinal surgery patients
Similarly, in bariatric surgery patients, anemia is the most common nutritional sequelae after surgery. In particular, patients who underwent malabsorptive surgery, including Roux-en-Y gastric bypass, showed a higher hemoglobin deficit than those who underwent restrictive surgery, including sleeve gastrectomy (24.4% vs. 40.0%) [10, 11].
ETIOPATHOGENESIS
Iron deficiency Iron deficiency is the most common cause of anemia after gastrointestinal surgery. It has also been reported that iron deficiency after partial gastrectomy causes anemia in 34% [12].
After ingestion of dietary iron, insoluble ferric iron (Fe3+) is reduced to ferrous iron (Fe2+) by ferric reductase at low pH. Ferrous iron is then absorbed from the duodenum by divalent metal transporter 1 (DMT-1) [13, 14]. Therefore, when bypassing the duodenum, iron absorption decreases, and the risk of iron deficiency increases. After subtotal gastrectomy, patients who underwent gastrojejunostomy have a significantly higher risk of iron deficiency than those who underwent gastroduodenostomy [9]. For bariatric procedures, Roux-en-Y gastric bypass also showed a higher risk of postoperative iron and hemoglobin deficit than gastric band [15]. Bile reflux or achlorhydria reduces acidity, resulting in impaired absorption of ferrous iron and subsequent iron-deficient anemia [16].
Iron loss from gastrointestinal bleeding is one of the causes of anemia [17]. Additionally, decreased iron intake following bariatric surgery also contributes to iron deficiency [11].
Vitamin B12 (cobalamin) deficiency Vitamin B12 is absorbed in the ileum, and it requires an intrinsic factor produced by parietal cells in the oxyntic mucosa of the stomach. When the oxyntic mucosa volume is reduced by partial or total gastrectomy, sleeve gastrectomy, or when the stomach is bypassed by bypass surgery, the risk of vitamin B12 deficiency increases, leading to megaloblastic anemia [16]. The incidence of vitamin B12 deficiency after malabsorptive surgery is reported to be 4% to 62%.
Rarely autoantibody to the parietal cells may cause autoimmune gastritis, leading to vitamin B12 deficiency and pernicious anemia. In this case, gastric acid produced by the parietal cells also decreases, which can be accompanied by iron deficiency.
Vitamin B9 (folate) deficiency Folate is a water-soluble vitamin and absorbed in the proximal small bowel. Folate deficiency has been reported for up to 38% of patients after gastric bypass surgery [18]. Decreased folate intake, deficiency of vitamin B12 as a coenzyme for folate absorption, and bypass of the proximal small bowel is a potential cause of folate deficiency after gastrointestinal surgery.
10https://e-fs.org https://doi.org/10.51666/fs.2021.1.e4
Anemia following gastrointestinal surgery is common and easily overlooked complication. Iron, vitamin B12, and folate deficiencies are common causes of postoperative anemia and aggravated by reduced dietary intake, gastrointestinal anatomy alteration, and decreased stomach acidity after surgery. Therefore, a comparative evaluation is required for prevention and supplementation before and after gastrointestinal surgery.
REFERENCES
1. Ando K, Morita S, Higashi T, Fukuhara S, Watanabe S, Park J, et al. Health-related quality of life among Japanese women with iron-deficiency anemia. Qual Life Res 2006;15:1559-63. PUBMED | CROSSREF
2. Ludwig H, Van Belle S, Barrett-Lee P, Birgegård G, Bokemeyer C, Gascón P, et al. The European Cancer Anaemia Survey (ECAS): a large, multinational, prospective survey defining the prevalence, incidence, and treatment of anaemia in cancer patients. Eur J Cancer 2004;40:2293-306. PUBMED | CROSSREF
3. Goddard AF, James MW, McIntyre AS, Scott BB; British Society of Gastroenterology. Guidelines for the management of iron deficiency anaemia. Gut 2011;60:1309-16. PUBMED | CROSSREF
4. Ioannou GN, Rockey DC, Bryson CL, Weiss NS. Iron deficiency and gastrointestinal malignancy: a population-based cohort study. Am J Med 2002;113:276-80. PUBMED | CROSSREF
5. Decker GA, Swain JM, Crowell MD, Scolapio JS. Gastrointestinal and nutritional complications after bariatric surgery. Am J Gastroenterol 2007;102:2571-80. PUBMED | CROSSREF
6. Gesquiere I, Lannoo M, Augustijns P, Matthys C, Van der Schueren B, Foulon V. Iron deficiency after Roux- en-Y gastric bypass: insufficient iron absorption from oral iron supplements. Obes Surg 2014;24:56-61. PUBMED | CROSSREF
7. Steenackers N, Gesquiere I, Matthys C. The relevance of dietary protein after bariatric surgery: what do we know? Curr Opin Clin Nutr Metab Care 2018;21:58-63. PUBMED | CROSSREF
8. Jeong O, Park YK, Ryu SY. Prevalence, severity, and evolution of postsurgical anemia after gastrectomy, and clinicopathological factors affecting its recovery. J Korean Surg Soc 2012;82:79-86. PUBMED | CROSSREF
9. Lee JH, Hyung WJ, Kim HI, Kim YM, Son T, Okumura N, et al. Method of reconstruction governs iron metabolism after gastrectomy for patients with gastric cancer. Ann Surg 2013;258:964-9. PUBMED | CROSSREF
10. Ferraz ÁA, Carvalho MR, Siqueira LT, Santa-Cruz F, Campos JM. Micronutrient deficiencies following bariatric surgery: a comparative analysis between sleeve gastrectomy and Roux-en-Y gastric bypass. Rev Col Bras Cir 2018;45:e2016. PUBMED | CROSSREF
11. Bavaresco M, Paganini S, Lima TP, Salgado W Jr, Ceneviva R, Dos Santos JE, et al. Nutritional course of patients submitted to bariatric surgery. Obes Surg 2010;20:716-21. PUBMED | CROSSREF
12. Hines JD, Hoffbrand AV, Mollin DL. The hematologic complications following partial gastrectomy. A study of 292 patients. Am J Med 1967;43:555-69. PUBMED | CROSSREF
13. Conrad ME, Umbreit JN. Iron absorption and transport-an update. Am J Hematol 2000;64:287-98. PUBMED | CROSSREF
14. Fleming RE, Bacon BR. Orchestration of iron homeostasis. N Engl J Med 2005;352:1741-4. PUBMED | CROSSREF
15. Sugerman HJ, Londrey GL, Kellum JM, Wolf L, Liszka T, Engle KM, et al. Weight loss with vertical banded gastroplasty and Roux-Y gastric bypass for morbid obesity with selective versus random assignment. Am J Surg 1989;157:93-102. PUBMED | CROSSREF
11https://e-fs.org https://doi.org/10.51666/fs.2021.1.e4
16. Rosenthal N, Abel HA. Simple achlorhydric anemia. Bull N Y Acad Med 1933;9:24-40. PUBMED
17. Baird IM, St John DJ, Nasser SS. Role of occult blood loss in anaemia after partial gastrectomy. Gut 1970;11:55-61. PUBMED | CROSSREF
18. von Drygalski A, Andris DA. Anemia after bariatric surgery: more than just iron deficiency. Nutr Clin Pract 2009;24:217-26. PUBMED | CROSSREF
12https://e-fs.org https://doi.org/10.51666/fs.2021.1.e4
INTRODUCTION
EPIDEMIOLOGY
ETIOPATHOGENESIS
ABSTRACT
Anemia is a common complication after gastric cancer and bariatric surgery and significantly influences the patient's postoperative recovery, quality of life, and long-term outcome. This article reviews the common etiopathogenesis of postoperative anemia following gastrointestinal surgery.
Keywords: Anemia; Gastrectomy
INTRODUCTION
Anemia is a common complication after gastrointestinal surgery and has a significant influence on the patient's postoperative recovery and the quality of life [1, 2]. Besides, anemia has been reported to increase the risk of malignancies of the gastrointestinal tract. Among the patients who underwent gastrectomy, patients with iron deficiency anemia have 2–3 times increased risk of gastric cancer after 20 years, and the risk of colon cancer is also likely to increase. Thus patients who underwent gastrointestinal surgery and older than 50 years of age are advised to perform gastrointestinal evaluations for anemia [3, 4].
Bariatric surgery for morbid obesity is increasing rapidly, and the most common nutritional complication after obesity surgery is anemia [5-7]. Therefore, the prevention and management of anemia are important in gastrointestinal surgery patients. However, due to physical and biochemical alterations in the gastrointestinal tract after gastrointestinal surgery, the management of anemia may not be effective in surgical patients. Hence, this review aimed to summarize the pathophysiology of anemia in gastrointestinal surgery patients.
EPIDEMIOLOGY
Postoperative anemia is one of the common complications after gastrectomy, and its incidence has been reported in more than 3/4 of patients immediately after surgery. The incidence declined over time and improved in about 40% of patients spontaneously three months after surgery. However, the remaining patients required proper management for the postoperative anemia [8].
Foregut Surg. 2021 Jan;1(1):9-12 https://doi.org/10.51666/fs.2021.1.e4 pISSN 2765-2890·eISSN 2765-3110
Review Article
Received: Jan 27, 2021 Accepted: Jan 27, 2021
Corresponding author: Minah Cho Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea. E-mail: [email protected]
Copyright © 2021. The Korean Society of Gastrointestinal Surgery This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https:// creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
ORCID iDs Minah Cho https://orcid.org/0000-0003-3011-5813
Funding The author has no financial support to disclose.
Conflict of Interest No potential conflict of interest relevant to this article was reported.
Minah Cho
Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
Etiopathogenesis of anemia in gastrointestinal surgery patients
Similarly, in bariatric surgery patients, anemia is the most common nutritional sequelae after surgery. In particular, patients who underwent malabsorptive surgery, including Roux-en-Y gastric bypass, showed a higher hemoglobin deficit than those who underwent restrictive surgery, including sleeve gastrectomy (24.4% vs. 40.0%) [10, 11].
ETIOPATHOGENESIS
Iron deficiency Iron deficiency is the most common cause of anemia after gastrointestinal surgery. It has also been reported that iron deficiency after partial gastrectomy causes anemia in 34% [12].
After ingestion of dietary iron, insoluble ferric iron (Fe3+) is reduced to ferrous iron (Fe2+) by ferric reductase at low pH. Ferrous iron is then absorbed from the duodenum by divalent metal transporter 1 (DMT-1) [13, 14]. Therefore, when bypassing the duodenum, iron absorption decreases, and the risk of iron deficiency increases. After subtotal gastrectomy, patients who underwent gastrojejunostomy have a significantly higher risk of iron deficiency than those who underwent gastroduodenostomy [9]. For bariatric procedures, Roux-en-Y gastric bypass also showed a higher risk of postoperative iron and hemoglobin deficit than gastric band [15]. Bile reflux or achlorhydria reduces acidity, resulting in impaired absorption of ferrous iron and subsequent iron-deficient anemia [16].
Iron loss from gastrointestinal bleeding is one of the causes of anemia [17]. Additionally, decreased iron intake following bariatric surgery also contributes to iron deficiency [11].
Vitamin B12 (cobalamin) deficiency Vitamin B12 is absorbed in the ileum, and it requires an intrinsic factor produced by parietal cells in the oxyntic mucosa of the stomach. When the oxyntic mucosa volume is reduced by partial or total gastrectomy, sleeve gastrectomy, or when the stomach is bypassed by bypass surgery, the risk of vitamin B12 deficiency increases, leading to megaloblastic anemia [16]. The incidence of vitamin B12 deficiency after malabsorptive surgery is reported to be 4% to 62%.
Rarely autoantibody to the parietal cells may cause autoimmune gastritis, leading to vitamin B12 deficiency and pernicious anemia. In this case, gastric acid produced by the parietal cells also decreases, which can be accompanied by iron deficiency.
Vitamin B9 (folate) deficiency Folate is a water-soluble vitamin and absorbed in the proximal small bowel. Folate deficiency has been reported for up to 38% of patients after gastric bypass surgery [18]. Decreased folate intake, deficiency of vitamin B12 as a coenzyme for folate absorption, and bypass of the proximal small bowel is a potential cause of folate deficiency after gastrointestinal surgery.
10https://e-fs.org https://doi.org/10.51666/fs.2021.1.e4
Anemia following gastrointestinal surgery is common and easily overlooked complication. Iron, vitamin B12, and folate deficiencies are common causes of postoperative anemia and aggravated by reduced dietary intake, gastrointestinal anatomy alteration, and decreased stomach acidity after surgery. Therefore, a comparative evaluation is required for prevention and supplementation before and after gastrointestinal surgery.
REFERENCES
1. Ando K, Morita S, Higashi T, Fukuhara S, Watanabe S, Park J, et al. Health-related quality of life among Japanese women with iron-deficiency anemia. Qual Life Res 2006;15:1559-63. PUBMED | CROSSREF
2. Ludwig H, Van Belle S, Barrett-Lee P, Birgegård G, Bokemeyer C, Gascón P, et al. The European Cancer Anaemia Survey (ECAS): a large, multinational, prospective survey defining the prevalence, incidence, and treatment of anaemia in cancer patients. Eur J Cancer 2004;40:2293-306. PUBMED | CROSSREF
3. Goddard AF, James MW, McIntyre AS, Scott BB; British Society of Gastroenterology. Guidelines for the management of iron deficiency anaemia. Gut 2011;60:1309-16. PUBMED | CROSSREF
4. Ioannou GN, Rockey DC, Bryson CL, Weiss NS. Iron deficiency and gastrointestinal malignancy: a population-based cohort study. Am J Med 2002;113:276-80. PUBMED | CROSSREF
5. Decker GA, Swain JM, Crowell MD, Scolapio JS. Gastrointestinal and nutritional complications after bariatric surgery. Am J Gastroenterol 2007;102:2571-80. PUBMED | CROSSREF
6. Gesquiere I, Lannoo M, Augustijns P, Matthys C, Van der Schueren B, Foulon V. Iron deficiency after Roux- en-Y gastric bypass: insufficient iron absorption from oral iron supplements. Obes Surg 2014;24:56-61. PUBMED | CROSSREF
7. Steenackers N, Gesquiere I, Matthys C. The relevance of dietary protein after bariatric surgery: what do we know? Curr Opin Clin Nutr Metab Care 2018;21:58-63. PUBMED | CROSSREF
8. Jeong O, Park YK, Ryu SY. Prevalence, severity, and evolution of postsurgical anemia after gastrectomy, and clinicopathological factors affecting its recovery. J Korean Surg Soc 2012;82:79-86. PUBMED | CROSSREF
9. Lee JH, Hyung WJ, Kim HI, Kim YM, Son T, Okumura N, et al. Method of reconstruction governs iron metabolism after gastrectomy for patients with gastric cancer. Ann Surg 2013;258:964-9. PUBMED | CROSSREF
10. Ferraz ÁA, Carvalho MR, Siqueira LT, Santa-Cruz F, Campos JM. Micronutrient deficiencies following bariatric surgery: a comparative analysis between sleeve gastrectomy and Roux-en-Y gastric bypass. Rev Col Bras Cir 2018;45:e2016. PUBMED | CROSSREF
11. Bavaresco M, Paganini S, Lima TP, Salgado W Jr, Ceneviva R, Dos Santos JE, et al. Nutritional course of patients submitted to bariatric surgery. Obes Surg 2010;20:716-21. PUBMED | CROSSREF
12. Hines JD, Hoffbrand AV, Mollin DL. The hematologic complications following partial gastrectomy. A study of 292 patients. Am J Med 1967;43:555-69. PUBMED | CROSSREF
13. Conrad ME, Umbreit JN. Iron absorption and transport-an update. Am J Hematol 2000;64:287-98. PUBMED | CROSSREF
14. Fleming RE, Bacon BR. Orchestration of iron homeostasis. N Engl J Med 2005;352:1741-4. PUBMED | CROSSREF
15. Sugerman HJ, Londrey GL, Kellum JM, Wolf L, Liszka T, Engle KM, et al. Weight loss with vertical banded gastroplasty and Roux-Y gastric bypass for morbid obesity with selective versus random assignment. Am J Surg 1989;157:93-102. PUBMED | CROSSREF
11https://e-fs.org https://doi.org/10.51666/fs.2021.1.e4
16. Rosenthal N, Abel HA. Simple achlorhydric anemia. Bull N Y Acad Med 1933;9:24-40. PUBMED
17. Baird IM, St John DJ, Nasser SS. Role of occult blood loss in anaemia after partial gastrectomy. Gut 1970;11:55-61. PUBMED | CROSSREF
18. von Drygalski A, Andris DA. Anemia after bariatric surgery: more than just iron deficiency. Nutr Clin Pract 2009;24:217-26. PUBMED | CROSSREF
12https://e-fs.org https://doi.org/10.51666/fs.2021.1.e4
INTRODUCTION
EPIDEMIOLOGY
ETIOPATHOGENESIS
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