ИСТИНА

Objectives: Obesity is an important public health scourge worldwide, which lately reached epidemic proportion. Bariatric surgery is the most effective way to cut and maintain weight among patients with morbid obesity. One of the methods is biliopancreatic diversion (BPD) which has the most frequent complications associated with macro-and micronutrient malabsorption Methods: We present a case of a 50-year-old female patient with secondary osteoporosis developed into severe osteoporosis after a BPD treatment performed 6 years previously. In the postoperative period, the necessary replacement therapy with calcium, vitamin D and other micro-and macronutrients had been taken irregularly; no long-term laboratory monitoring was provided due to the lack of appropriate recommendations. On admission, she wasn´t able to move because of severe pain and edematous syndromes, her height decreased by 10-12 cm. The dual energy X-ray absorptiometry confirmed severe osteoporosis (T-score of radius total-5,6 SD, L1-L4-3,4 SD and total hip-4,2 SD). The X-ray demonstrated multiple consolidated fractures of ribs. The laboratory data indicated severe hypoproteinemia (total protein 38 g/L), hypocalcemia (ionized calcium 0.99 mmol/l), 25(OH) vitamin D deficiency (5.6 nmol/l) and an increased rate of parathyroid hormone (562,6 pg/ml). Ultrasound revealed signs of hyperplasia of the right upper parathyroid gland (1.0x0.8x0.4 cm). Results: Our treatment started with enhanced infusion therapy of albumin and diuretics with the response of positive diuresis and a loss of excess fluid. Next, the therapy aimed to replenish the deficiency of calcium (calcium carbonate 2 g), vitamins A, D (colecalciferol 800 IU and alfacalcidol 2 μg), E, B, iron, folic acid, digestive enzymes and protein. Long-term bisphosphonate therapy is prescribed after normalization of calcium-phosphorus metabolism. Upon re-examination after the relief of the malabsorptive syndrome and an improvement of general somatic state. During 2 years of follow-up, the patient moved independently, did not presented new fractures; an increase of bone mineral density was observed (T-score of radius total-5,1 SD, L1-L4-2,3 SD and total hip-2,4 SD), the laboratory test showed normalization of biochemical parameters. Conclusion: The lack of compulsory lifelong replacement therapy and a follow-up management leads to side effects, including severe osteoporosis due to malabsorption-related vitamin D deficiency. Keeping all risk factors for osteoporotic fractures under control is necessary to prevent a decrease of life quality in the extreme case of patient's disability.