Belly Pain After Bypass: Internal Hernias

We are fortunate to have a new PA in the practice we are training these days.  Even more fortunate for us that she comes with a surgical background. I am looking forward to getting her up to speed in the Bariatric world as she adjusts to the likely newfound 'intimacy'of the Family Practice-style setting we enjoy, as compared to her most recent position in the Surgical house staff at an area hospital, seeing many patients and usually hoping not to see them back again.

Bariatric Surgery really is a little different.  It has the typical aspects of any surgical practice, but we also continue to follow patients for at least a year after surgery, as well as seeing them weekly for weight loss and MD visits prior to surgery.  Hard not to get 'attached' to them in a more intimate way as they journey through the weight loss process.  Reminds me in certain aspects of my Family Practice days..

So, as my teaching often goes, when a patient you have known for a while through regular followups, comes in with abdominal pain, whether severe or subacute, current or recent in temporal history, take notice.  As seen with the last Blog post on abdominal pain, pain is not 'normal' after bypass (or sleeve or Band for that matter), and requires a thoughtful history to sort out.

Internal Hernias after Gastric Bypass can present with pain from intermittent / nuisance quality, or severe, as well as that of dead bowel if neglected long enough.  Their abdominal pain comes from the bowel obstruction that happens internally, not the hernia space itself.

From ScienceDirect.com

At the time of the Bypass surgery, in order to reposition the mid-small intestine to link up with the newly-formed gastric pouch, and then distally create the "Y", where biliopancreatic secretions enter the ingested food 'downstream' (think malabsorption), the mesentery that attaches to the small intestine must be transected.  At the time of the surgery, care is taken to close these hernia spaces.  The tissue we close is mainly fatty, and although it can initially hold sutures fairly well, over time and with resultant weight loss, the spaces can reopen and cause a Partial Small Bowel Obstruction, or even a more acute situation with a bowel obstruction or strangulation.

Internal Hernias and their associated bowel obstructions occur after Bypass at a rate of about 9%.

We usually say "100# lost / 1 year out of surgery" as a rough guide, although we have seen patients present earlier, and certainly later, and with less weight loss.  The majority do generally seem to follow this rule.

Symptoms are variable, but often a high index of suspicion will lead us to the OR for a diagnostic laparoscopy rather than a CT scan.

The pain is often Left sided, intermittent, and not related to eating or activities.  There may be mild / vague associated intermittent obstructive complaints (nausea, emesis, BM habit changes), but not always. As stated earlier, with an acute presentation, they may look like an SBO, or even sicker if incarcerated for a while (hours to days).
 

So, if they fit the rough criteria as above, and their pain both is consistent with what we usually see with this complication, as well as not sounding like any other pattern of either a Bariatric or non-Bariatric cause of abdominal pain, we may be going to the OR, either as an elective or an emergent case.  CT scans often do not show anything specific, unless there is an acute nature to the PSBO or SBO, however a 'mesenteric swirl sign' is diagnostic, but infrequently seen.  Of course, a CT may show another cause of the pain, but best practice is to just give us a call to evaluate the patient and expedite their care.

And just so you are clear, because the patients often are not...

Abdominal wall hernias (Ventral) are very common after open Gastric Bypass (which we very rarely do), whereas they are relatively rare after laparoscopic surgery.  Again, this defect causing the more common variety PSBO and its attendant pain after Bypass is "internal", rather than external as with an abdominal wall hernia.

And further, it is actually thought that due to reduced internal inflammation with the laparoscopic approach than the open approach, internal hernia rates are higher than that of the open surgical approach for that reason.

That's enough for today.

Let's be careful out there.

Belly Pain After Bypass: Marginal Ulcer

Photo from Medscape.com

I saw a patient in the office just the other day with pretty severe abdominal pain, and I thought this might be a good place to  make mention of its cause, incidence, symptoms, treatment and prognosis.

Marginal Ulcer is fairly common after Gastric Bypass, and actually has been around for a long time, described in the literature as an occasional complication of GI surgery in general.  It's incidence is reported as 6-16% of bypass patients, and can occur as early as a few months after surgery to years later.

Patients often present with varying degrees of epigastric abdominal pain, from nuisance-quality to occasionally very severe in nature. It can be associated with some dysphagia, nausea, and anorexia, as well as vomiting and even hematemesis.  Should the pain and/or the symptoms worsen, keep in mind that perforation can occur, and will present as a perforated viscus does.

The history, other than the specifics of the character of the presenting pain, often will further direct the diagnosis.  Smoking and NSAID use, (despite repetitive pre op counsel against the same) are very often the causative factors.  In those without that history, environmental stressors, or even malnutrition may also predispose, but less likely.

Diagnosis is made definitively by Endoscopy (above), but empiric Rx with a notable improvement over 5 -7 days on appropriate treatment can also support the diagnosis, and make EGD unnecessary.

Appropriate treatment consists of a PPI such as Nexium at a higher dose of 40 mg BID, along with Carafate 1g 4 x per day as a slurry or in liquid form.  The Carafate slurry can be created by dissolving a 1g pill in a couple of oz of warmish water and drinking it down.  Swallowing the pill whole will likely pass through the gastric pouch too quickly and diminish its effectiveness. Analgesics such as Lortab may be required for the short term until meds start to take effect.

Paramount to the treatment plan is the strict abstinence from smoking and all NSAID use. Other gastric irritants such as ETOH and caffeine and acidic foods should also be minimized especially if they cause symptoms upon ingestion.

We have seen the occasional patient who continues their smoking or NSAID use, and they commonly recur after they have healed up, or may continue to exhibit moderate to severe symptoms despite maximal medical therapy.

At Endoscopy, if a patient has had prolonged symptoms and has a craterous ulcer that is not healing, we may be able to fibrin glue the defect to encourage healing, but results with this approach have been mixed at best.

Operative treatment may eventually be needed on the rare occasion if the ulcer perforates, or if chronic pain and ulcer are associated with resultant malnutrition.  The approach to that issue can come down to a reversal of the Gastric Bypass - a difficult procedure, but a possibility if it's the only reasonable option left.

The bottom line is, for us and for you in Primary Care is this: Catch an ulcer early, treat it appropriately, and support the patient getting off NSAIDS by offering alternatives, as well as strongly supporting nicotene abstinence by counseling and perhaps a Chantix Rx.  Patients that continue to smoke are at a much greater risk for recurrence and perforation than those who do not.

B12 Deficiency and Weight Loss Surgery: Solving the Energy Crisis with Beet Juice?

Photo by M Clock

I remember well the cute old ladies that would come into the Family Practice I used to work in and request their monthly dose of "Beet Juice" to pep them up and help keep them active and sassy.

If it worked anecdotally, that was fine with me, as B12 was relatively cheap and seemed to make a positive difference in their reported energy level and their health in general. I used to check labs to see if they were anemic,  check their MCV to see if they were macrocytic, or check and see if they had prior gastric surgery or chronic PPI usage, or a past history of an issue with their intrinsic factor. Usually not on all accounts.  But they still wanted it...

I checked for my own interest, as well as the insurance companies who did not want to pay for a regular dose of B12 for fatigue or malaise (code 780.79).  You know how that is.

With my setting now in Bariatric Surgery, it is a little different story.  Risk factors abound in our patients, and often lead to B12 deficiencies that CAN be detected in labwork.  Our patients obviously have a history of past Gastric Bypass or Sleeve Gastrectomy, or they may have the history of poor compliance with the lifelong vitamin regimen that is heavy in B vitamins (B12 1,000 mcg per day, and B Complex one daily).

The recommended dosing is generally one B12 tablet daily, but can be given IM once per month, sublingually, or even intranasally (Nascobal) as well.

We do tend to have patients on PPIs for 3 mos after surgery to allow for staple lines to heal satisfactorily, and patients may use them prn after that.  Obviously, with a  much smaller stomach with the Bypass more than the Sleeve, and less exposure of food / vitamin nutrients in the pouch to acid and intrinsic factor, substantially less B12 will be absorbed.  We describe this side effect of surgery to patients to encourage compliance with their vitamin regimen, but occasionally they fall short of regular dosing.

With B12 deficiency, we will often see neurological complaints such as depression, memory issues, or symmetrically peripheral neuropathies of tingling / burning / and numbness in the hands or feet or upper extremities.  Fatigue and malaise may also be reported, but is usually multifactorial and not B12 specific.

Having them restart their B12, or getting them off to a better start with an IM injection in the office usually makes a difference in no time, which becomes reassuring.  These neurological complaints may become permanent if long lived, or severe in nature.

Catching B12 issues early, as with most nutritional issues, with regular lab work and a detailed history on our follow up visits (especially in the first year) definitely makes a difference. Another reason why follow up is so important.

Exhibit G: The Patient is Always Right

From HowStuffWorks / TLC

Not sure who to "thank" for this next patient scenario- the Patient or Dr. Oz.

So, amid the day's scheduled (and unscheduled) patient visits, I saw in follow up a Diabetic patient, or should I say 'formerly Diabetic', who was 1 mos S/P a Sleeve Gastrectomy.  

She relayed a tale of her pursuit of Bariatric Surgery despite a number of obstacles.  Apparently her Primary MD initially put her off for a few weeks.  

Then when she asked the other MD in her practice to consent to her having surgery,  he replied, "That is the worst thing you can do.  A patient like you with not much can lose can do it easily with exercise and diet, and you DON'T need surgery."  She went back to the first MD she saw in the practice, and she consented to her having a Bypass.

Bringing her to the necessity that surgery was what she needed was the fact that for her, the next step in her DM Rx was insulin.  She said "No way; Not me".

She was further emboldened by experiences in her own family.  She has an overweight sibling with DM2 on an insulin pump, and another sibling with DM2 with pancreatitis and obesity who awaits a different type of intestinal bypass procedure,  along with a partial pancreatectomy and pseudocyst drainage.  She has extended family that are all suffering with the disease and its complications.

I asked her where she got her information about the metabolic benefits of weight loss surgery, and she replied "Dr. Oz, of course!"

Demographics:  52 y/o WF

Start Weight:  226  BMI:  36

Date of Surgery:  12/12  Gastric Bypass

DM Hx:  She presented to us on Metformin 1000 BID, Glyburide 25 BID, and destined for insulin after maxing out on medical therapy.  She had attempted to lose weight at onset of her Diabetes, and repeated her attempts thereafter at non-surgical weight loss, unfortunately to no durable avail.  Duration of Diabetes diagnosis was about 4 years.

Current DM Hx:  She is now 1 mos post op from her Sleeve, and off antidiabetic agents since the time of her surgery as she recovered in the hospital for one day post op.  She still tests her BGs at home on occasion, but less and less now that her post op high has been 118, and she often is less than 100 mg/dl before meals.  She is understandably ecstatic with her "non-diabetic" status now, and also further encouraged by her current weight of 189 / BMI 30 when seen today.

Take Home Point:  The information revolution claims another victory. Patients are more informed now than ever, although not     necessarily properly informed, and certainly not just about this issue of Diabetes and obesity.  

As you know, they commonly will question you about your antibiotic choice, or suggest a differential diagnosis that may either be thought-provoking, or a true zebra- but it's all in play now.  I have heard that Dr. Oz had a series of programs on obesity, surgery, and Diabetes Rx, and was well-received by the media and patients alike.  

Having surgery for this patient was, and will be, a win-win for her and the MD as it plays out in terms of long-term health and her DM remission, and likely resolution (I do not know her C-Peptide to even comment on that one).

As I have stated earlier, and it still remains an absolute truth: Surgery is not for everyone.  It may be clinically indicated for many, and even very likely to be significantly life-altering (in a positive way) for a good proportion of those, but timing and patient "buy in" is everything.  The degree that behavior dictates both short and long term efficacy of the procedure mandates this.  

And you, as PCPs, are the best to decide if someone is ready, willing, and medically able to take that next step, and likely to be a winner in the 'risk vs. benefit' arena.  

But, be on guard.  Your patient may pop the question before you do, and will be expecting an informative, compassionate response in reply.

Post Op Protein Malnutrition: A Word or 2 From Hans and Franz

From  SNL

We should hire Hans and Franz for the office.

Our post op patients could use some motivation ("I WANT to PUMP YOU UP") at times, as we commonly see varying degrees of protein malnutrition after surgery, most notably the Gastric Bypass, and lesser so after the Sleeve and the Band.

Protein malnutrition can be a result of the same causes as Fe deficiency: Malabsorption, and/or preferential food limitation by the patient for proteins, which are usually texturally more difficult to eat after surgery due to newfound gastric restriction.

Patients who don't follow our slogan of "Protein First" when they eat a meal start out with CHO-rich foods, and end up with little room for proteins by the end of their 1/2 - 3/4 cup meal.  They need to maintain focus on protein intake preferentially, as to get to the recommended 60-80 grams of protein intake every day.

Studies have shown that 60-80 grams per day will encourage weight loss by sustaining a reasonable metabolic rate, maintain a good amount of satiety to lessen hunger, and uphold lean body mass as weight loss occurs.

Of note, out preoperative weight loss program is essentially a high protein / low CHO diet of either Medifast shakes, and/or a Lean and Green diet as instructed by our Nurses or our Dietician.  It works!

As referenced earlier in this Blog, we check labs regularly in our patients after surgery, every 3 mos for the first year in Bypass and Sleeve patients, and roughly every 6 mos in our Band patients.  Included in our post op panel is a PreAlbumin level.  Albumin is not as sensitive in the short term, whereas PreAlbumin is a better marker of acute protein malnutrition.  Advising our patients to increase (or adhere to) their suggested protein intake will often positively effect a low protein level in a short amount of time.

Our Registered Dietitian has developed an excellent resource for our patients that describes the reason protein is so important, how much they need daily, types of foods and serving sizes that a patient may try to get their protein in, and how to read labels on protein-containing foods and supplemental shakes to get the best ones out there.

A word about supplemental proteins.  Most shakes out there from any reputable source (Price Chopper, Walmart, GNC, etc.) are "Complete Proteins" that have all the 9 essential Amino Acids necessary for human biological function, and are usually Soy or Whey based.  The best ones for weight loss patients are those with low CHO, as to not add extra calories, or induce Dumping Syndrome, as can occur after a Bypass and a high CHO load.

Signs of insufficient protein intake may include anemia, asthenia, edema, and alopecia. Physical exam evidence of muscle wasting, if it is severe and chronic in nature, can be seen in the dorsal hands as well as the major muscle groups.

So, in summary, as far as protein intake goes...Just Do It, or else...

Post Op Iron Deficiency: From Nuisance to Nasty



From The Savvy Sister

When we have a discussion about complications after Bariatric Surgery, we usually speak of the "big ones" (PE, death, DVT, staple line leak, bleeding, Infection, obstruction, Hernia...).

Much more prevalent, and usually of a nuisance character, are the micronutrient deficiencies.  These most typically occur after malabsorptive surgeries (Gastric Bypass, also Duodenal Switch), but can occur with restrictive procedures as well (Gastric Band and Sleeve Gastrectomy).

With the former, nutrient absorption is altered or significantly diminished by "bypassing" the anatomical sites where absorption is physiologically preferred.  With the restrictive surgeries, nutrient absorption remains essentially unaffected, but due to significantly less nutritional intake and perhaps maladaptive eating styles post-surgery, the same can result.

We do check a full panel of labs on our new patients, and often find a number of pre-existent abnormalities on the nutritional side.  It is not uncommon to see depressed Vitamin D levels, low Fe, as well as a mild to moderate microcytic anemia from Fe deficiency.  Of note, our patient population is about 75% female, and most in their child bearing years.


Post op, we start checking labs at 3 mos, unless indicated earlier.  As far as Fe goes, we check Fe level / TIBC/Ferritin/and %Fe Saturation along with a CBC.  We can occasionally start seeing some deficiency developing 6 mos or so after surgery, despite a regular supplemental schedule with vitamins and minerals.  Compliance with the vitamin regimen is not uncommonly an issue, and is the first-line of treatment if  levels are low.  We have patients take a bariatric all-inclusive vitamin (Fusion) 4x per day, or our standard mix of vitamins is as follows:

   *Multivitamin with Fe daily
   *B12 1,000 mcg daily
   *B Complex Daily
   *Calcium Citrate 500 with D BID

If we need additional Fe, we use OTC Ferrous Sulfate 325, preferrably BID, with some vitamin C to enhance absorption.  Should a patient either not respond to, or be GI intolerant with the PO form and have deteriorating Fe stores, a Hematology consult is warranted for IV Fe.

A review of the symptoms goes along with what you would think you would see with Fe deficiency / anemia, with fatigue, new DOE, palpitations, pica / pagophagia (chewing on ice), sometimes vague abdominal pain, headaches, malaise, weakness, even syncope, etc.  These are a myriad of  vague compaints, actually, that as isolated complaints could be easily overlooked, but put in context of a post op weight loss patient, definitely need a further evaluation. 

And, as per the previous post on Follow up, we do check our post op panel every 3 mos for the first year to detect a nutritional issue early, or evaluate current treatment status of a previously treated one.

Myth Buster #5: Patient Behavior is the Primary Determinant of Outcomes After Bariatric Surgery

From MythBusters, Discovery Channel

I found this to be one of the most interesting Myths to be Busted so far.

The idea that there really were other significant determinants of outcomes, more than behavior, piqued my interest.  I know how many times we have discussed results of the various procedures (and various patients) and wondered what the various factors were, but we always seem to start and end with behavior.  Admittedly, that does seem to be such a huge part of the result of the surgery for an individual patient, but is there more...?

Studies have been done demonstrating the wide variability of results from patient to patient, albeit in a moderately narrow range.  This is exemplified by one study of Gastric Bypass patients who fell within a standard deviation of 20% Excess Weight Loss (EWL) amongst a studied group of 150 patients.

Furthermore, the variability of results also extends to other outcomes of surgery, including the magnitude of weight regain, DM2 improvement, lipid levels, HTN, and occurrence of adverse metabolic and nutritional effects.

Coming to an understanding of the basis of this variability would likely improve the overall utility of surgery, in a couple of ways.  With improved predictive value in terms of patient-specific beneficial and adverse outcomes, there would be an overall improvement in risk-benefit (and cost-benefit) profiles to Bariatric surgical procedures.  Also, that same information could be used to increase the understanding regarding how to improve results in patients that would be thought of as at higher risk of complications or not faring as well as others.  That latter group may still be a patient (DM2) that stands to gain a significant benefit from the surgery, or one that has no other real non-surgical option left.

The factors associated with weight loss surgery success vary from clinical to non-clinical components.

Clinical contributors that have been studied to reveal significantly better weight loss after Gastric Bypass are lower preoperative BMI, absence of DM2, higher capacity for physical exertion, higher education level, and greater participation in postoperative care.

Non-Clinical factors fall into mostly the description of genetics.  A few studies have looked at identical twins, genetically-related adults, and non-related cohorts of patients, and have shown repetitively that there is a strong genetic contribution to weight loss after Gastric Bypass.  In the identical twin group, the weight loss only varied by an average of 1.5% between the 2 pairs of twins. Yikes.  This is likely the start of a new field in medicine-"Surgicogenomics".

So, in summary, there is increasing recognition of multiple aspects to success after Bariatric Surgery- behavioral, physiological and genetic.  I still would have to say that behavior is the main determinant for success after surgery, but there are a few other factors at work as well that need further exploration.   With more information will come more insight into patient selection, procedure selection, improved results, and diminished untoward effects.


Adapted from Kaplan, Seeley, Harris.  "Patient behavior is the primary determinant of outcomes after bariatric surgery".  The Metabolic Applied Research Strategy, a supplement to Bariatric Times Vol 9 No 9.  C18-21.