Dr. Keith Roach

Dear Dr. Roach: I’m a 78-year-old retired medical oncologist. While in residency in New York, I got a gastrointestinal virus that left me with lactose intolerance. After a while, it improved somewhat. But in the past couple of years, using Lactaid tabs when I ate yogurt started not to be enough, and I was plagued by liquid stools once a day to the point where I was having a very hard time. Also, I was having trouble maintaining my weight.
I went to see my GI doc, who put me on Metamucil and seconded my decision to avoid all lactose-containing foods. Things have improved considerably, and I am no longer having weight maintenance problems. I’ve never seen any reports about lactase deficiency causing malabsorption, but I’m pretty convinced that severe lactase deficiency in my case may have caused malabsorption. What do you think? — J.M.C., MD
Answer: Lactose is a natural sugar found mostly in milk and milk products like cheese and yogurt. During adulthood, many people (including about 2/3 of the world’s population) lose the ability to make the enzyme lactase, which breaks down lactose into its component parts. Without that enzyme, lactose cannot be absorbed (malabsorption).
Lactose intolerance is when there are symptoms of the malabsorption, such as the diarrhea you mention. But symptoms also include abdominal pain, bloating and gas. This is because the lactose is fermented by bacteria once it reaches the colon, which turn the milk sugar into fatty acids, hydrogen, methane and carbon dioxide. Lactaid is one brand of lactase enzyme. When taken with lactose-containing foods, a lactase replacement allows the body to process those foods normally.
Even though the milk sugar can’t be absorbed in a person with lactase deficiency, weight loss is uncommon. When it occurs, it is often due to people consciously or unconsciously changing their diet to avoid the foods that cause symptoms.
Weight loss should prompt an investigation into whether another nutrient is also being malabsorbed. Loss of the ability to absorb fat causes significant weight loss. Celiac disease and small intestinal bacterial overgrowth are malabsorption syndromes that can sometimes mimic pure lactase deficiency. The fact that your weight stabilized with proper treatment of your lactase deficiency suggests that there are no other worrisome causes in your case.
Dear Dr. Roach: In 2015 I had my mitral valve replaced with a pig valve. By going this route, I realize it is not a permanent fix. How long should I expect this valve to last before requiring replacement? I’m a 70-year-old male. The recovery from the open-heart surgery was brutal, so I am not looking forward to doing it again. — D.B.
Answer: You can plan on living a long time, since more than 50% of bioprosthetic valves (like the porcine valve you have) are still working fine after 20 years. Only about 20% of people with a bioprosthetic mitral valve need replacement after 15 years.
In those much younger than you, the risk of deterioration of the valve is higher, so a mechanical valve is usually recommended for those age less than 55 at the time that they need a new valve. A mechanical valve is expected to last a lifetime, but even these very rarely develop mechanical faults.
A relatively new procedure, called a transcatheter mitral valve implantation, may be an option for people who are older or who have a higher risk for traditional surgery. Transcatheter valve replacement is already a very important treatment for aortic valve replacement, and may be adopted more commonly with the mitral valve in the future.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected] or send mail to 628 Virginia Dr., Orlando, FL 32803.
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