Stomach Problems with Weight Loss Surgery

Heartburn...

The first twelve weeks after surgery is when most patients experience this.  RNY patients have an advantage in that reflux is essentially cured by this operation.  There are some simple things you can do to prevent GERD (heartburn):

• Fluid and food portion control (see Simpson commandment number one).
• Elevate the head of your bed about 15 degrees. Many of you will sleep in a recliner the first couple of weeks.  Some of you will use pillow wedges in bed, and others will have elevated hospital beds.
• Caffeine, alcohol, and chocolate increase GERD by relaxing the sphincter between the stomach and the esophagus.  During the first twelve weeks you may not want to be consuming the alcohol or chocolate anyway. Norwegians are allowed coffee.
• Carbonated beverages are forbidden by some surgeons.  No plop plop, fizz, fizz for you.  But these beverages can exacerbate reflux.
• You may need to add the Reglan® at night along with the Pepcid.  You may need some stronger medicine, such as Prevacid, Nexium, etc.
• Tums, or better yet, Pepcid Complete which gives you immediate relief from the acid and also a longer-term relief.

Diarrhea

Not only can high protein keep your stools loose, so can your new anatomy.  Four loose stools a day is common for duodenal switch or a long-limb Roux-en-Y bypass.  You may need to bulk up your diet with soluble fiber such as Citrucel®, or a generic based methylcellulose.  We don’t recommend psillium seed products as they can cause gas.  Milk products can also cause diarrhea after surgery, anytime guts are rearranged patients can find themselves intolerant of lactose.  If you have black stools, if you have blood in your stools, or if the diarrhea persists for more than two days, call your surgeon.  DO NOT, on your own, take products to stop the diarrhea.

If you have an antibiotic associated colitis, taking Kaopectate or Lomotle can make it much worse.  But diarrhea is a matter of degree, for some patients just having loose stools is considered diarrhea, as surgeons we don’t think that way.  Two large-volume very loose stools is considered diarrhea.  Some surgeons, myself included, have patients undergo a bowel prep before surgery  and sometimes this prep solution is still in the patient, so their first bowel movement can be explosive.  Fats can cause diarrhea, as they are not digested well in distal bypass patients.

Constipation

Constipation is not fun—it is awful, and it is a common problem with proximal RNY, VBG, and lap band.  The answer is always the same, it never varies—you need to drink more water.  Of course, everyone tells me that they drink "gallons" of water, and it doesn’t matter.  Simply put—your colon absorbs water, it will absorb more water if you are in need of it—if you drink a lot of water then it won’t absorb as much and you will have lose stools.  The second solution is soluble fiber.  We recommend fiber which is based on methylcellulose (like Citrucel®—which you can purchase in a sugar free variety).  In fact, we also recommend fiber for patients who have loose stools—as it will help "bulk" them up a bit.  So, fiber and water are the keys. Oh—one more thing—walk.  The more you walk, the better the bowels move, the less you walk, the slower they get.  So, water, walk, and fiber.  Do not start taking laxatives—you can become dependent upon them and they are not something you wish to become dependent upon.  Have a glass of Citrucel and take a brisk walk.

Hemorrhoids

A hemorrhoid is a painful complex of veins in the rectum that can cause bleeding, itching, soiling and even pain.  Some say they are varicose veins of the rectum caused by abnormal straining.  This is caused by two conditions—diarrhea and constipation. If you bring reading material into the bathroom with you, then you are set up for hemorrhoids.  Preventing them is simple: have fiber and water—same answer for both diarrhea and constipation.  For both you need to have more soluble fiber to bulk up the stools and increase your water intake.  We recommend a methylcellulose fiber such as Citrucel, as it has less gas than fiber made from seeds.

There are a few things that you can do to help relieve the symptoms from hemorrhoids—first, though, we recommend you see your surgeon to make certain that your problem is a hemorrhoid and not something else that needs treatment.  Tucks® are a great product.  Use them according to the directions, and you will find a lot of relief from the pain, swelling and itching from hemorrhoids.  There are various creams and ointments that people use for the hemorrhoids but often the over-the-counter medications just don’t work that well.  A Sitz bath is a device you can find at many pharmacy outfits that will allow you to soak the backside in some nice warm water.  Some like it hot, some like it cold, and some like it warm.  It doesn’t matter what temperature you use the Sitz bath, use what feels good and take them often, but just limit them to 20 minutes at a time.  Sometimes you need to have surgery for the hemorrhoids, and if that thought doesn’t get you to use fiber and water, after the surgery you will be purchasing the stuff anyway.

Everyone does it.  In the hospital I ask daily if patients have passed flatus, and they are quite happy when they do.  However, outside the hospital people are not so happy to be passing gas.  Gas comes from two sources: swallowed air and bacteria in your gut breaking down some food that your body doesn’t digest.  The foods that are known to cause most gasses are beans (shocking), some fruits, soft drinks, whole grains/wheat and bran, milk and milk products, foods containing sorbitol and dietetic products.

Devrom® or Nullo® can help eliminate some odors.  You can order Dev–rom at (800) 453-8898, or their website htp://www.parthenoninc.com.

If you feel a bulge under your incision, you might have a hernia.  If the bulge comes out when you strain, lift, or cough, and goes back in when you lay down, you probably have a hernia and your surgeon will want to see you in the office to confirm it.  Hernias become larger with time and will need repair.  They do not improve on their own, no exercise will help them, they will grow, they will get worse, and they can cause a problem.  Sometimes the hernia, or bulge, does not go back—and we have a cute term for that—incarcerated (as in jail).

Hernias can be painful but usually they are not. Sometimes you strain your incision when you lift things, and if you do, you need to give your muscles a rest: a strain is not a hernia.  The pain from a hernia can be sharp or it can be a dull ache that feels worse at the end of the day.  Remember, your fascia (gristle) is what holds you together and after surgery your stomach is held together by the sutures that are about thirty pound test line.  Those sutures are strongest when first put in and dissolve over time, and at the same time your body is healing that fascia together.  Some surgeons use permanent sutures that do not dissolve over time, but these to not guarantee there will be no hernia formation.

Often hernias happen about a month after surgery when people feel fine and then lift something heavy.  The most common patients who develop hernias are mothers; it is hard to resist picking up your child, especially a month after surgery when you are feeling better.  If you have a hernia it will only become larger with time, and you will need to have surgery.  If you have a hernia, and  you suddenly develop pain, nausea and vomiting, call your surgeon immediately; do not wait for an appointment.

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Other Problems

Some patients are prone to a yeast infection, which either manifests itself as thrush (a painful white coating of the tongue) or a rash under the armpits, in the groin area or in the skin.  These happen for a variety of reasons; the most common reasons are antibiotic use.  The antibiotics wipe out "friendly" bacteria that inhabit the skin and mouth and other places, allowing yeast to take over.  When I had knee surgery they used a single dose of antibiotics and I developed the worst case of jock itch—another fungus.  There are some over the counter products for this and prescriptions are available for severe cases.

Hair thinning or loss is expected after rapid weight loss.  There are those who firmly believe that protein, taking biotin or other vitamins and supplements, prevents this.  There is hair loss that is associated with zinc deficiency, protein deficiency and other deficiencies of vitamins and minerals, but this is a rare contributing factor to post operative patients’ hair loss.  For those thirty percent who have hair loss, the hair will come back, fuller and richer than before.  No shampoo will prevent it, but perms and coloring may accelerate hair loss during this time.

The realm of hair-care products, the amount of things that salons put into your hair and scalp, remind me of toxic waste dumps.  Makes me wonder why more people don’t lose hair.  I mean think about it: people with curly hair have products designed to straighten their hair, people with straight hair get stuff to curl their hair, if you are blonde you want to be more blonde or a redhead, if you are auburn or brown you want to be blonde or black, and if you are grey—well, then all is lost and it is time to find out what Clairol has to make your hair any color but that.

Hair loss is caused from the hair follicles resetting themselves in the face of the stress of surgery, weight loss, and other factors we do not understand.  A lot of people will sell you a lot of products to prevent hair loss.  You can spend your money on these products but I would prefer you purchase this book, be educated and support my pocket instead of your local hairdresser’s.

You may resume sexual activity when you feel up to it.  Don’t forget birth control.  We would like you to wait two years before getting pregnant.  For birth control during this time we recommend a diaphragm, condoms, an IUD, or even the patch, but not the pill.  Some oral contraceptives are not absorbed well after this surgery.  Planning for your pregnancy is better than being surprised and naming the child after your favorite surgeon.

As stated above, we recommend that you avoid this issue so use birth control religiously (Okay, there are some who would have a problem with that, so for those, just avoid).  You may start planning a pregnancy after 12 months, although most surgeons prefer for you to wait 24 months to conceive.  If you become pregnant, we will need to enlist the aid of a good OB doctor.

The period of rapid weight loss during your first post operative year is not a healthy time to nourish a fetus.  Children are a great addition to most families, and I am very pro-kids (no, I am not available for baby sitting and I do not want to borrow your teenager).  There are many patients who undergo weight loss surgery specifically to have children, and to those of you who fit into this category—good luck.