Severe hypoalbuminaemia after Roux-en-Y gastric bypass: a diagnosis of exclusion

Bariatric surgery has emerged as a highly effective treatment option for individuals with obesity. Severe hypoalbuminaemia is a feared complication after a Roux-en-Y gastric bypass. It is characterised by a low serum albumin level of <25 g/l, neither explained by renal losses, protein-losing enteropathy nor by liver disfunction, and is associated with high morbidity and mortality. Prompt workup leading to the diagnosis and aggressive treatment are recommended to prevent rapid clinical worsening; however, evidence-based recommendations and specific treatment approach are lacking. Most cases can be managed with dietary counselling and protein-enhanced oral supplements. We report a case of a female patient in her 50s with class II obesity, who underwent a Roux-en-Y gastric bypass eight months earlier, who presented to the Emergency Department with new onset of asthenia and lower limb oedema. Her biochemistry panel revealed severe serum hypoalbuminaemia, with a level of 18.4 g/l. After a thorough examination, complete laboratory tests and imaging that excluded renal and gastrointestinal losses and hepatic disfunction, she was presumed to have developed severe hypoalbuminemia after bariatric intervention. She managed to increase her oral intake of protein-enhanced products, according to nutritional counselling. At a six-month follow-up visit the patient regained 1% of the weight and had a slow and progressive increase in the serum albumin level. Our report highlights the importance of continuous nutritional monitoring and a multidisciplinary approach in the post-operative period of bariatric surgery to improve long-term outcomes.