Copper Deficiency After Gastric Surgery: A Reason for Caution

doi:10.1097/MAJ.0b013e31818ad0ff

The American Journal of the Medical Sciences

Volume 337, Issue 4, April 2009, Pages 256-258

https://doi.org/10.1097/MAJ.0b013e31818ad0ff Get rights and content

Abstract

Background

Acquired copper deficiency in adults leads to hematological and neurological manifestations that mimic vitamin B12 deficiency. A significant number of patients with copper deficiency syndrome have a history of gastric surgery, often remote. We sought to determine whether copper deficiency is present in a population of individuals with longstanding partial gastric resection.

Methods

Serum copper, ceruloplasmin, and zinc levels were determined in 20 patients with a history of partial gastric resection and 50 controls, randomly selected from the Oklahoma City Veterans Affairs Medical Center electronic database.

Results

Hypocupremia and symptoms of copper deficiency were detected in patients with partial gastric resection in contrast to controls (3/20 versus 0/50, P = 0.02). Serum copper and ceruloplasmin levels were significantly lower in individuals with partial gastric resection than in controls (P = 0.04 and P = 0.001, respectively). The mean interval between gastric surgery and testing was 20.7 years.

Conclusions

Our results indicate that a significant number of individuals with longstanding history of partial gastric resection have undiagnosed hypocupremia. Screening for copper deficiency after gastric surgery may prevent the development of hematological and neurological complications in these patients.

Section snippets

PATIENTS AND METHODS

The study was approved by the University of Oklahoma Institutional Review Board. Informed consent was obtained from all participants.

Twenty patients with a prior diagnosis of partial gastric resection and 50 controls were randomly selected using the Veterans Affairs Decision Support System (VADSS) electronic database. VADSS selection used International Classification of Diseases-9 diagnoses entered during clinic appointments between January 1, 2000 and March 31, 2005. Exclusion criteria for

RESULTS

Clinical and laboratory findings in patients with a prior diagnosis of partial gastric resection (n = 20) and controls (n = 50) are summarized in Table 1. The distribution of serum copper and ceruloplasmin levels in the 2 groups is presented in Figure 1.

Serum copper levels were significantly lower in individuals with a history of partial gastric resection compared with controls (mean ± SD, 92.1 ± 25.2 versus 103.0 ± 20.3 μg/dL, P = 0.04). Similar differences were noted in serum ceruloplasmin levels,

DISCUSSION

Our findings document that unrecognized copper deficiency is present in significantly more patients with longstanding partial gastric resection compared with randomly selected controls. The mechanism of copper deficiency in these patients is likely related to the key role played by stomach and proximal duodenum in oral copper absorption.¹⁴ Although hyperzincemia and prolonged parenteral nutrition are known to cause copper deficiency, none of the patients had elevated serum zinc levels or

ACKNOWLEDGMENTS

The authors thank Dr. P. Comp for the critical review of the manuscript.

REFERENCES (21)

KumarN.
Copper deficiency myelopathy (human swayback)
Mayo Clin Proc
(2006)
GreggX.T. et al.
Copper deficiency masquerading as myelodysplastic syndrome
Blood
(2002)
FinebergH.V. et al.
Surgical treatment of peptic ulcer in the United States. Trends before and after the introduction of cimetidine
Lancet
(1981)
KumarN. et al.
Acquired hypocupremia after gastric surgery
Clin Gastroenterol Hepatol
(2004)
BottomleyS.S.
Sideroblastic anemias
SchleperB. et al.
Copper deficiency-associated myelopathy in a 46-year-old woman
J Neurol
(2001)
ProdanC.I. et al.
CNS demyelination associated with copper deficiency and hyperzincemia
Neurology
(2002)
KumarN. et al.
Myeloneuropathy and anemia due to copper malabsorption
J Neurol
(2004)
WeihlC.C. et al.
Motor neuron disease associated with copper deficiency
Muscle Nerve
(2006)
SpinazziM. et al.
Myelo-optico-neuropathy in copper deficiency occurring after partial gastrectomy: do small bowel bacterial overgrowth syndrome and occult zinc ingestion tip the balance?
J Neurol
(2007)

There are more references available in the full text version of this article.

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La chirurgie œsogastrique est indiquée majoritairement pour pathologie tumorale. Elle est grevée d’une forte morbi-mortalité. Les modifications anatomiques qui découlent des montages chirurgicaux sont pourvoyeuses d’une prévalence élevée de dénutrition postopératoire immédiate mais aussi à long terme. Cette dénutrition, souvent méconnue et insuffisamment prise en charge, influence négativement, et indépendamment de tout autre facteur, autant la qualité de vie que la survie sans récidive tumorale. La prévention passe par un dépistage précoce de la dénutrition et une surveillance systématique les cinq à dix ans qui suivent la chirurgie. Une meilleure connaissance des mécanismes sources de la dénutrition et des principales carences en nutriments est essentielle pour une prise en charge optimisée et efficace.
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: The study was supported by the Oklahoma City Veterans Research and Education Foundation.

View full text

Clinical InvestigationCopper Deficiency After Gastric Surgery: A Reason for Caution

Abstract

Background

Methods

Results

Conclusions

Section snippets

PATIENTS AND METHODS

RESULTS

DISCUSSION

ACKNOWLEDGMENTS

Mayo Clin Proc

Blood

Lancet

Clin Gastroenterol Hepatol

Sideroblastic anemias

Copper deficiency-associated myelopathy in a 46-year-old woman

J Neurol

CNS demyelination associated with copper deficiency and hyperzincemia

Neurology

Myeloneuropathy and anemia due to copper malabsorption

J Neurol

Motor neuron disease associated with copper deficiency

Muscle Nerve

Myelo-optico-neuropathy in copper deficiency occurring after partial gastrectomy: do small bowel bacterial overgrowth syndrome and occult zinc ingestion tip the balance?

J Neurol

Clinical Investigation
Copper Deficiency After Gastric Surgery: A Reason for Caution