Case Reports

Indian Pediatrics 2001; 38: 665-667  

Short Bowel Syndrome: Unusual Cause of Vitmain K Deficiency

Manuscript received: September 4, 2000; Initial review completed: September 29, 2000; Revision accepted: December 20, 2000.

Short Bowel Syndrome (SBS) is a group of symptoms and signs resulting from a length of bowel which is inadequate to sustain nutrition. Since the major function of small intestine is digestion of food and absorption, most common features of SBS are malnutri-tion, diarrhea and fluid and electrolyte disturbances alongwith deficiency of various nutrients(1,2). Deficiency of vitamin K though theoretically possible is not a common clinical finding(3). This case is being reported to highlight this potentially life threatening and easily preventable clinical condition.

A ten-year-old non-vegetarian male child presented to us with history of spontaneous ecchymotic patches over face, forearms and lower limbs off and on for one year. There was no history of mucosal or joint bleeding and no family history of bleeding diathesis was elicited. He also gave history of bulky, frothy and foul smelling stools with repeated acute exacerbations for past one year. Two years back the patient had undergone intestinal resection extending from duodeno-jejunal flexure to 30 cm proximal to ileocecal junction because of volvulus and gangrene of small bowel. He had received antitubercular treatment and antiepileptic drugs for tuber-culoma one year back. The antitubercular drugs had been stopped but he still continued taking carbamazepine. Three months before presenting to us he was hospitalized else-where for cellulitis of right thigh along with diarrhea. He had been investigated and his prothrombin time was found to be prolonged and platelet count was normal.

On examination, the patient was grossly emaciated (weighing 18 kg) and lethargic. He had purpuric and ecchymotic patches all over the body and his skin was dry and rough. There was no anemia, lymphadenopathy or hepatosplenomegaly. Examination of other systems was normal. Results of his hemato-logical investigations were: Hb = 13.2 g/dl, MCV-88.4 f1, TLC-11, 300/mm3, DLC-L-84, N-14, E-2, platelet count 203 ´ 103/mm3, PT >1 min (control 13 seconds) and PTTK 83.9 seconds (control 32.2 seconds). Liver func-tion tests showed serum ALT 32 IU/L, AST 34 IU/L, Serum bilirubin 1.1 mg/dl (direct 1.0 and indirect 0.1 mg/dl). Renal function tests and serum sodium were normal but his serum potassium was 1.35 mEq/L.

The patient was given intravenous potassium supplementation and intravenous vitamin K 5 mg/day for 3 days. He also received multivitamin and calcium supple-mentation. His diet was modified to improve nutrition. After 3 days of vitamin K therapy, new ecchymotic patches stopped appearing and old lesions started fading. Now his PT was 12.9 seconds (control 13.0 seconds) and PTTK was 25.6 seconds (control 25.0 seconds). Since both PT and PTTK normal-ized after vitamin K therapy, diagnosis of vitamin K deficiency as a result of SBS was made. The patient was discharged from hospital once his dyselectrolytemia normal-ized and bleeding stopped.

Vitamin K deficiency related hemorrhagic disease of newborn is a well recognized clinical entity. More recently cases beyond the usual presentation in early neonatal period and in infancy have been described - the late hemorrhagic disease(4,5). Most of these infants were breastfed, had diarrhea and received antibiotics. Such a setting of diarrhea and exposure to antibiotic therapy in presence of dietary deficiency or malnutrition has resulted in bleeding manifestations in adults also(3,6). In otherwise normal individuals, clinically overt vitamin K deficiency is rare as the requirement of vitamin K is very small and vitamin K is also synthesised in the gut(7).

Along with other conditions causing malabsorption such as celiac disease, tropical sprue, regional ileitis and ulcerative colitis, SBS also has been described to cause vitamin K deficiency(6,8). SBS more commonly presents with recurrent and intractable diarrhea and undernutrition. Deficiency of calcium and magnesium may occur. Anemia is also a common problem. The determinants of severity of symptoms are - extent of intestinal resection, site of resection and patency of ileocecal junction. The manage-ment of SBS comprises energetic fluid therapy during initial phase of massive diarrhea. Total parenteral nutrition may be required. Once diarrhea starts subsiding, gradual introduction of enteral nutrition is done. Commencement of complete enteral nutrition may take 2-3 months. It is in this phase that status of various nutrients should be assessed and supplemented(1,2).

In the present case, malabsorption of vitamin K due to SBS was complicated by frequent episodes of diarrhea during which he might have received antibiotics resulting in further decrease in the already compromised vitamin K stores. The child had developed bleeding manifestations since the past one year but vitamin K deficiency was not immediately considered by the treating physician, probably because the bleeding was exclusively cutaneous. As he was on a non-vegetarian diet and medicinal supple-mentation, anemia was not evident. His normal MCV ruled out sub-clinical deficiency of iron and folate also.

To conclude, since repeated episodes of diarrhea requiring antibiotic therapy are common in SBS, prevention of vitamin K deficiency should be kept in mind. As the oral medicinal preparations of vitamin K are not easily available, a diet rich in vitamin K should be prescribed. Assessing coagulation status by doing PT and PTTK at 4-6 weeks intervals and after episodes of diarrhea or exposure to antibiotics may be useful for monitoring vitamin K requirement.

Contributors: JC drafted the paper and will act as guarantor for the paper. SC reviewed the literature. SN helped in investigating the case. VS helped in preparing the manuscript.

Funding: None.
Competing interests: None stated.

Key Message

Short bowl syndrome (SBS) commonly present as recurrent/intractable diarrhea and malnutrition alongwith deficiency of various nutrients. Vitamin K deficiency can occur in SBS due to malabsorption and repeated use of antibiotics for diarrhea. Vitamin K deficiency needs to be prevented in SBS.

 

1. Townsend Jr. CM, Thompson JC. Small Intestine. In: Principles of Surgery. 6th edn. Eds. Schwartz SI, Shires GT, Spence FC, Husser WC. New York, McGraw Hill, 1994; pp 1153-1189.

2. Rombeau JL, Rolandelli RH. Enteral and parenteral nutrition in patients with enteric fistulas and short bowel syndrome. Surg Clin N Amer 1987; 67: 551-570.

3. Martinez J, Barsigian C. Coagulopathy of liver failure and Vitamin K deficiency. In: Thrombosis and Hemorrhage, Loscalzo J, Schafer Ai. Williams and Wilkins, Baltimore, 1998; pp 987-1004.

4. Marwaha RK, Kumar A, Garewal G, Marwaha N, Walia BNS. Vitamin K defi-ciency related bleeding manifestations in older neonates and infants. Indian Pediatr 1987; 24: 307-311.

5. Merchant RH, Dovekar R, Shah MD. Late Hemorrhagic disease of infancy. Indian Pediatr 1989; 26: 553-557.

6. Ansell JE, Kumar R, Deykin D. The spectrum of Vitamin K deficiency. J Am Med Assoc 1977; 238: 40-42.

7. Frick PG, Reidler G, Brogli H. Dose response and minimal daily requairement for Vitamin K in man. J App Physiol 1967; 23: 387-389.

8. Grosset ABM, Rodgers GM. Acquired coagulation disorders. In: Wintrobes Clinical Hematology, Vol. II edn. Eds. Lee GR, Foerster J. Lukens J, Paraskevas F, Greer JP, Rodgers GM. Williams and Wilkins, Baltimore, 1999; pp 1733-1780.