title: Hypoparathyroidism after Roux-en-Y gastric bypass--a challenge for clinical management: a case report.
abstract: BACKGROUND
  In this report, we describe challenges we encountered in the clinical management of a patient with hypoparathyroidism who had previously undergone a bariatric procedure.
  
  
  METHODS
  We report the case of a 38-year-old Caucasian woman who had undergone a Roux-en-Y gastric bypass procedure for treatment of obesity. She also had a past history of right lobectomy to treat a benign thyroid nodule. Another thyroid nodule was diagnosed after her bariatric surgery, so a new thyroid surgery was performed. Permanent hypoparathyroidism occurred after the second thyroid surgery. A Roux-en-Y gastric bypass resulted in important weight loss, but the preferential site of calcium absorption was bypassed. The lack of endogenous parathyroid hormone secretion due to post-surgical hypoparathyroidism abolished the physiological mechanism that compensates the reduced calcium absorption, which was a challenge for us to overcome. In this report, we describe our clinical therapeutic choices to maintain normocalcemia and normophosphatemia in this patient. Higher doses of exogenous calcium citrate, calcitriol and cholecalciferol were used, but hypocalcemia was still present. To improve vitamin D absorption with resultant improvement of calcium homeostasis, we speculated that adding pancrelipase to meals would increase lipid absorption and possibly fat-soluble vitamins, including vitamin D. Only after the addition of pancrelipase did the patient improve without weight regain according to clinical and laboratory assessments.
  
  
  CONCLUSIONS
  The use of exogenous pancreatic enzymes improved calcium homeostasis in this bariatric patient. The role of these enzymes on vitamin D absorption and subsequent rise in calcium levels in hypoparathyroid patients who undergo bariatric procedures need further investigation.
authors.forename: Diogo Guarnieri
authors.initials: DG
authors.lastname: Panazzolo
authors.forename: Tássia Gomide
authors.initials: TG
authors.lastname: Braga
authors.forename: Anice
authors.initials: A
authors.lastname: Bergamim
authors.forename: Bárbara
authors.initials: B
authors.lastname: Pires
authors.forename: Hirlena
authors.initials: H
authors.lastname: Almeida
authors.affiliation: Obesity Unit, Polyclinic Piquet Carneiro; Endocrinology, Department of Internal Medicine, Medical Sciences Faculty, State University of Rio de Janeiro, Av, Marechal Rondon, 381, Rio de Janeiro 20950-003, Brazil. gkraemer@ig.com.br.
authors.forename: Luiz Guilherme
authors.initials: LG
authors.lastname: Kraemer-Aguiar
mesh_terms: D000328:Adult; D005260:Female; D015390:Gastric Bypass / Q000009:adverse effects*; D006801:Humans; D007011:Hypoparathyroidism / Q000188:drug therapy / Q000209:etiology*; D009765:Obesity / Q000150:complications / Q000601:surgery; D016606:Thyroid Nodule / Q000150:complications / Q000601:surgery; D013965:Thyroidectomy / Q000009:adverse effects