Obesity Surgery

, Volume 21, Issue 12, pp 1971–1974 | Cite as

The Importance of Methylmalonic Acid Dosage on the Assessment of Patients with Neurological Manifestations Following Bariatric Surgery

Case Report


Vitamin B12 or cyanocobalamin is an important substance that is included in several metabolic pathways. Its deficiency is a common event after bariatric surgery, decreasing the vitamin B12 absorption after almost all of the stomach and duodenum are eliminated from the digestion process. Neurological manifestations of cyanocobalamin deficiency are not uncommon. We report a case of a young woman who developed ataxia, weakness and peripheral neuropathy after bariatric surgery, but with normal value of vitamin B12 dosage. For the diagnosis, it was necessary to dose methylmalonic acid. We discuss the importance of methylmalonic acid dosage after bariatric surgery in patients who present suspect of cyanocobalamin deficiency with normal values of this vitamin and the role of proton pump inhibitor use and vitamin supplementation in patients with early neurological presentation.


  1. 1.
    Carmel R, Green R, Rosenblatt DS, et al. Update on cobalamin, folate, and homocysteine. Hematology Am Soc Hematol Educ Program 2003;62–81Google Scholar
  2. 2.
    Allen RH, Stabler SP, Savage DG, et al. Metabolic abnormalities in cobalamin (vitamin B12) and folate deficiency. FASEB J. 1993;7:1344–53.PubMedGoogle Scholar
  3. 3.
    Stabler SP, Allen RH, Savage DG, et al. Clinical spectrum and diagnosis of cobalamin deficiency. Blood. 1990;76:871–81.PubMedGoogle Scholar
  4. 4.
    Snow CF. Laboratory diagnosis of vitamin B12 and folate deficiency: a guide for the primary care physician. Arch Intern Med. 1999;159:1289–98.PubMedCrossRefGoogle Scholar
  5. 5.
    Morris MS, Jacques PF, Rosenberg IH, et al. Elevated serum methylmalonic acid concentrations are common among elderly Americans. J Nutr. 2002;132:2799–803.PubMedGoogle Scholar
  6. 6.
    Allen LH, Rosado JL, Casterline JE, et al. Vitamin B-12 deficiency and malabsorption are highly prevalent in rural Mexican communities. Am J Clin Nutr. 1995;62:1013–9.PubMedGoogle Scholar
  7. 7.
    Diez-Ewald M, Torres-Guerra E, Layrisse M, et al. Prevalence of anemia, iron, folic acid and vitamin B12 deficiency in two Bari Indian communities from western Venezuela. Invest Clin. 1997;38:191–201.PubMedGoogle Scholar
  8. 8.
    Vargas-Ruiz AG, Hernandez-Rivera G, Herrera MF. Prevalence of iron, folate, and vitamin B12 deficiency anemia after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2008;18:288–93.PubMedCrossRefGoogle Scholar
  9. 9.
    Rhode BM, Arseneau P, Cooper BA, et al. Vitamin B-12 deficiency after gastric surgery for obesity. Am J Clin Nutr. 1996;63:103–9.PubMedGoogle Scholar
  10. 10.
    Halverson JD, Zuckerman GR, Koehler RE, et al. Gastric bypass for morbid obesity: a medical–surgical assessment. Ann Surg. 1981;194:152–60.PubMedCrossRefGoogle Scholar
  11. 11.
    Amaral JF, Thompson WR, Caldwell MD, et al. Prospective hematologic evaluation of gastric exclusion surgery for morbid obesity. Ann Surg. 1985;201:186–93.PubMedCrossRefGoogle Scholar
  12. 12.
    Brolin RE, Gorman JH, Gorman RC, et al. Are vitamin B12 and folate deficiency clinically important after roux-en-Y gastric bypass? J Gastrointest Surg. 1998;2:436–42.PubMedCrossRefGoogle Scholar
  13. 13.
    Alvarez-Leite JI. Nutrient deficiencies secondary to bariatric surgery. Curr Opin Clin Nutr Metab Care. 2004;7:569–75.PubMedCrossRefGoogle Scholar
  14. 14.
    Parkes E. Nutritional management of patients after bariatric surgery. Am J Med Sci. 2006;331:207–13.PubMedCrossRefGoogle Scholar
  15. 15.
    Skroubis G, Sakellaropoulos G, Pouggouras K, et al. Comparison of nutritional deficiencies after Roux-en-Y gastric bypass and after biliopancreatic diversion with Roux-en-Y gastric bypass. Obes Surg. 2002;12:551–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Healton EB, Savage DG, Brust JC, et al. Neurologic aspects of cobalamin deficiency. Medicine (Baltimore). 1991;70:229–45.Google Scholar
  17. 17.
    Kumar S. Recurrent seizures: an unusual manifestation of vitamin B12 deficiency. Neurol India. 2004;52:122–3.PubMedGoogle Scholar
  18. 18.
    Kvittingen EA, Spangen S, Lindemans J, et al. Methionine synthase deficiency without megaloblastic anaemia. Eur J Pediatr. 1997;156:925–30.PubMedCrossRefGoogle Scholar
  19. 19.
    Abarbanel JM, Berginer VM, Osimani A, et al. Neurologic complications after gastric restriction surgery for morbid obesity. Neurology. 1987;37:196–200.PubMedGoogle Scholar
  20. 20.
    Thaisetthawatkul P, Collazo-Clavell ML, Sarr MG, et al. A controlled study of peripheral neuropathy after bariatric surgery. Neurology. 2004;63:1462–70.PubMedGoogle Scholar
  21. 21.
    Carmel R. Current concepts in cobalamin deficiency. Annu Rev Med. 2000;51:357–75.PubMedCrossRefGoogle Scholar
  22. 22.
    Marcuard SP, Albernaz L, Khazanie PG. Omeprazole therapy causes malabsorption of cyanocobalamin (vitamin B12). Ann Intern Med. 1994;120:211–5.PubMedGoogle Scholar
  23. 23.
    Juhasz-Pocsine K, Rudnicki SA, Archer RL, et al. Neurologic complications of gastric bypass surgery for morbid obesity. Neurology. 2007;68:1843–50.PubMedCrossRefGoogle Scholar
  24. 24.
    Lindenbaum J, Savage DG, Stabler SP, et al. Diagnosis of cobalamin deficiency: II. Relative sensitivities of serum cobalamin, methylmalonic acid, and total homocysteine concentrations. Am J Hematol. 1990;34:99–107.PubMedCrossRefGoogle Scholar
  25. 25.
    de Mello CF, Begnini J, Jimenez-Bernal RE, et al. Intrastriatal methylmalonic acid administration induces rotational behavior and convulsions through glutamatergic mechanisms. Brain Res. 1996;721:120–5.PubMedCrossRefGoogle Scholar
  26. 26.
    Malfatti CR, Royes LF, Francescato L, et al. Intrastriatal methylmalonic acid administration induces convulsions and TBARS production, and alters Na+, K+−ATPase activity in the rat striatum and cerebral cortex. Epilepsia. 2003;44:761–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Dahele A, Ghosh S. Vitamin B12 deficiency in untreated celiac disease. Am J Gastroenterol. 2001;96:745–50.PubMedCrossRefGoogle Scholar
  28. 28.
    Gultepe M, Ozcan O, Avsar K, et al. Urine methylmalonic acid measurements for the assessment of cobalamin deficiency related to neuropsychiatric disorders. Clin Biochem. 2003;36:275–82.PubMedCrossRefGoogle Scholar
  29. 29.
    Holleland G, Schneede J, Ueland PM, et al. Cobalamin deficiency in general practice. Assessment of the diagnostic utility and cost-benefit analysis of methylmalonic acid determination in relation to current diagnostic strategies. Clin Chem. 1999;45:189–98.PubMedGoogle Scholar
  30. 30.
    Norman EJ. Urinary methylmalonic acid/creatinine ratio defines true tissue cobalamin deficiency. Br J Haematol. 1998;100:614–5. author reply 617–618.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science + Business Media, LLC 2011

Authors and Affiliations

  1. 1.Clinic of Neuromuscular Diseases, DINEP–Neurology and Epidemiology Division, University Complex Professor Edgar SantosFederal University of BahiaSalvadorBrazil

Personalised recommendations