Other stomach problems that may occur after weight loss surgery

Heartburn

Heartburn is when the acid from your stomach goes into your esophagus and burns it—it is also known as Gastro-esophageal reflux disease (GERD). If you over fill your stomach, you will have GERD. There is a bit more to reflux disease than this. Obesity is related to reflux, so is pregnancy (the excess weight presses on the diaphragm). 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

(keeping it loose)

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 (vodka and Go-lytely is called the Simpson cocktail) 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

—sung to Carly Simon’s “anticipation”

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 real pain in the…

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.

Flatulence

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.

Hernia

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.

My mentor in surgery was a great surgeon named George Block. He closed all abdominal incisions with wire on the inside. When you learned to tie the wire suture, you passed his rotation, I really loved Dr. Block and became a surgeon because of him, but I hated tying wire sutures.

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