Case report Jejunal villous atrophy with morbid obesity: death after

SUMMARY A 49-year-old woman with morbid obesity was found to have subtotal villous atrophy in an operative jejunal biopsy, taken when a jejunoileal bypass was created. After the operation, the patient developed marked weight loss, vomiting, hepatic failure, and a bizarre mental state with sudden losses of consciousness. Six months after the first operation the bypass was reversed but the patient developed hepatorenal failure and died one week after the second operation. The histological features of several biopsies of jejunum were typical of a gluten sensitive enteropathy. This, previously subclinical, small bowel disease may have contributed to her hepatic failure and death by interfering with jejunoileal adaptation. In the absence of any of the other, rarer, causes of villous atrophy, this woman appears to have had coeliac disease. The unexpected finding of an abnormal jejunal mucosa, with villous atrophy, is usually due to subclinical coeliac disease, or dermatitis herpeti-formis, although immunodeficiency, giardiasis, or gastrinoma 2 are other, rarer, causes. This report concerns a woman who was found to have jejunal villous atrophy at the time of jejunoileal bypass surgery, and in whom the diagnosis is likely to have been coeliac disease. Case report A 49-year-old woman weighing 140 kg (22 stone) was referred to the Gastro-Intestinal Unit, Western General Hospital, Edinburgh, in June 1978 for assessment for jejunoileal bypass surgery (Fig. 1). In her early 20s she had weighed 89 kg (14 stone) and had increased to 120 kg after the birth of her only child when aged 28 years. For the two years before referral she had attended an obesity clinic where, despite weekly visits, repeated dietetic advice and treatment with fenfluramine, she had managed to lose only a few kilograms, quickly regained. Besides her obesity and some features of reactive Address for correspondence and reprint requests: Gastro-Intestinal Unit