De novo ulcerative colitis and Takotsubo cardiomyopathy following sleeve gastrectomy

Discussion

Multiple case series and studies have shown the occurrence of de novo IBD following bariatric surgery, although the mechanism remains unclear. Ungaro et al identified fifteen patients with a new diagnosis of IBD following bariatric surgery.6 Most cases were women who had Roux-en-Y gastric bypass, 10 cases developedCrohn’s disease, 4 cases ulcerative colitis and 1 case an unclassified IBD. Their group also conducted a matched case–control study using medical and pharmacy claims from 2008 to 2012 in a US national database. Their study included 8980 cases and 43 059 controls. A history of bariatric surgery was associated with an increased risk of new-onset IBD (OR 1.93, 95% CI 1.34 to 2.79).6 Similar findings were appreciated by Braga Neto et al who reviewed records from Mayo Clinic and Washington University School of Medicine from 1 January 1996 to 31 December 2016 and identified 44 patients who developed de novo IBD after bariatric surgery.5

Notably, this same group from the Mayo Clinic also has a prospectively maintained database on all bariatric surgery cases. From 1 January 1996 to 31 December 2016, 3709 patients underwent bariatric surgery at Mayo Clinic, and the incidence of IBD in this patient population was 26.7 per 100 000 person-years. The age-adjusted standardised incidence ratio (SIR, observed divided by expected) ranged from 3.56 in the 40–49 year age group to 4.73 in the 30–39 years age group. The expected number was derived using age-adjusted and sex-adjusted incidence rates of Crohn’s disease in Olmstead County, Minnesota (1970–2010).5

Patients who have had recent bariatric surgery may experience non-specific symptoms including nausea, vomiting, diarrhoea, abdominal pain or weight loss, similar in presentation as IBD. Thus, a strong clinical suspicion of IBD is important as delays in diagnosis can have adverse outcomes. An IBD flare can cause emotional and physiological stress on the body, which may lead to TTS in susceptible patients. Mirijello et al described multiple cases of concurrent IBD and TTS and noted several similarities between these diseases such as higher prevalence among females, recurrent disease course, association with endothelial dysfunction and affective disorders.8

Most cases of TTS have a preceding emotional or physical stress which triggers a rise in the circulating catecholamine levels, with subsequent circulating catecholamine-mediated microvascular dysfunction and myocardial stunning.9 In the USA, TTS incidence was approximated between 15 and 30 cases per 1 00 000 patients per year.11 This syndrome affects women more often than men. The International Takotsubo Registry had 1750 patients with takotsubo cardiomyopathy, 89.8% of them were women, predominantly postmenopausal.12

Prompt differentiation of TTS from acute coronary syndrome, acute viral or autoimmune myocarditis is essential. TTS can be identified by changes in ST segments on ECG that extend beyond the perfusion territory of a single coronary artery, and by lack of significant elevations in biomarkers of myocardial injury.9 10 Furthermore, TTS can be distinguished from ACS by a high pro-BNP to troponin ratio, reflecting the relatively minor myocyte necrosis but significant ventricular dysfunction.9

This patient’s non-classical LV apical ballooning can hypothetically be related to variation in myocardial beta-1 and beta-2 adrenergic receptors density between apical and basal segments.8 9 As with this patient, most patients with TTS will recover left ventricular systolic function within weeks, while others can have complications such as heart failure and arrhythmias.9 10

To our knowledge, this is the first case of TTS following new-onset ulcerative colitis after sleeve gastrectomy. After bariatric surgery, TTS and de novo IBD are both rare, underdiagnosed and more common in women.5 11 As discussed earlier, TTS disproportionately affects postmenopausal women, and there is evidence suggesting oestrogen deficiency may play a key role in the pathogenesis of TTS. Due to decreased levels of oestrogen, postmenopausal women have an increased sympathetic drive and endothelial dysfunction.13 14 Ueyama et al established an elegant animal model for TTS using ovariectomised rats, and their experiments showed oestrogen supplement improves the stress-induced cardiovascular dysfunction by indirect action on the nervous system and by direct action on the heart.15 Fu et al used an injection of high dose epinephrine to induce TTS in adult rats and in human-induced pluripotent stem cells-derived cardiomyocytes, and they showed that activation of G protein-coupled oestrogen receptor which executes the rapid effects of oestrogen prevented an increase in left ventricular internal diameter at end-systole and a decrease both in ejection fraction and cardiomyocyte shortening amplitude in epinephrine-induced TTS.16 Excess adiposity is associated with increased oestrogen, and weight loss is associated with decreased oestrogen levels. Rock et al showed that postmenopausal women who lost ≥5% of body weight at 6 months had significantly lower estrone, estradiol and bioavailable estradiol concentration than women who did not lose at least 5% of body weight.17 The patient in our case lost approximately 20% of her body weight in the 3 months following her laparoscopic sleeve gastrectomy. We hypothesise that the acutely reduced level of oestrogen due to loss of adipose tissues combined with the physiological stress of IBD contributed to TTS in our patient. Due to the limited number of case reports, we cannot prove such cause or effect, and further research is needed to further understand the pathophysiology of TTS and guide future therapies.