Case 20-2008: Abdominal Pain and Weakness after Gastric Bypass Surgery

To the Editor: In the discussion of the Case Record by Bonkovsky et al. (June 26 issue) 1 about a patient with porphyria who became symptomatic after gastric bypass surgery, there was no mention of the patient's nutritional care, which may have played a major contributory role. The persistent ketonuria before hospitalization indicates a daily carbohydrate intake of less than 100 g, whereas the very low serum creatinine level on admission indicates limited meat intake and a marked reduction in skeletal muscle, reflecting severe protein-calorie malnutrition. 2 These findings are consistent with limited energy and protein intake postoperatively, which was at least . . .