LETTER TO THE EDITOR Letter: Celiac Disease Presenting After a Single Anastomosis Duodeno-Ileal Bypass and Sleeve Gastrectomy Amelie Therrien 1,2 & Marie-Pierre Renaud 1,3 & Lilia-Maria Sanchez 4 & Louise D’Aoust 1 & Michel Lemoyne 1 # Springer Science+Business Media, LLC, part of Springer Nature 2019 Dear Editor, With great interest, we read the article written by Freeman and colleagues about the implications of celiac disease (CeD) among patients undergoing a gastric bypass [1]. The authors concluded that Roux-en-Y gastric bypass (RYGB) is safe for individuals with CeD. They reported on 68 patients who had abnormal serology or pathology prior to the operation, with only three individuals being diagnosed with CeD. However, acknowledging that CeD, and even celiac crisis, may be triggered following a sur- gery [2, 3]; it is important to know if among the 65 re- maining patients with some abnormalities, new CeD cases were diagnosed after the bariatric surgery. We would also like to highlight Bcase 1, ^ a 42-year-old lady, non- adherent to the gluten-free diet (GFD), who lost 100% of excess weight in the first year after surgery. These questions were raised by a recent case of CeD at our institution, presenting with excessive weight loss 4 months after a single anastomosis duodeno-ileal bypass and sleeve gastrectomy (SADI-S). A 46-year-old woman presented in the emergency depart- ment (ED) with ongoing chronic diarrhea, steatorrhea, and nausea since her bariatric surgery 4 months earlier. Her past medical history included type 2 diabetes (T2D) complicated by allergies to several forms of insulin, cirrhosis due to non- alcoholic steatohepatitis (NASH), hypothyroidism, and psori- atic arthritis for which she was on anti-TNF drugs once a week. Her BMI was 44, and considering her difficulties to lose weight and the coexisting disorders, bariatric surgery was proposed. She previously denied any gastrointestinal symptoms except for occasional acid reflux. Low ferritin level (7 μg/L) led to a colonoscopy, which revealed two polyps. She already had two EGD for esophageal varices assessment, which also did not show any bleeding. Tissue transglutaminase antibodies (tTG) were initially low positive (7 U/mL, threshold for positivity > 8 U/mL, low positive 5– 7 U/mL) on a gluten-containing diet, but deamidated gliadin peptides (DGP) IgA were elevated, 51.7 U/mL and IgG 46.8 U/mL (threshold > 30 U/mL). Duodenal biopsies were not performed before the surgery. She underwent a SADI-S with a common channel of 250 cm. After the surgery, the patient lost 94 pounds over 4 months, which was about 62% of her excess weight. She developed loose greasy stools triggered by alimenta- tion and associated with urgencies, nausea, anorexia, and abdominal cramping. On initial evaluation at the ED, there were no physical signs of malnutrition except for mild pedal edema. Hemoglobin and ferritin level were within normal range, the patient being on iron supplements since the surgery. Folates and vitamin B 12 levels were also * Amelie Therrien atherri1@bidmc.harvard.edu Marie-Pierre Renaud marie-pierre.renaud.1@ulaval.ca Lilia-Maria Sanchez lilia-maria.sanchez.chum@ssss.gouv.qc.ca Louise D’Aoust louise_daoust@sympatico.ca Michel Lemoyne michel.lemoyne@sympatico.ca 1 Department of Medicine, Division of Gastroenterology, Centre Hospitalier de l’Université de Montreal, 1051 Sanguinet, Montreal H2X 0C1, Canada 2 Present address: Beth Israel Deaconess Medical Center, East Campus, Gastroenterology 330 Brookline Ave, Boston, MA 02115, USA 3 Present address: Hôpital Anna-Laberge, 200 Boul Brisebois, Châteauguay J6K 4W8, Canada 4 Department of Pathology, Centre Hospitalier de l’Université de Montréal, 1100 rue Sanguinet, Pavillon F, Montreal H2X 0C2, Canada Obesity Surgery https://doi.org/10.1007/s11695-018-03678-3