Flatulence Diarrhea and Irritable Bowel Syndrome

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Problems related to flatulence, diarrhea, and irritable bowel syndrome (IBS) are very common among adult patients with or without GERD.38 It is therefore to be expected that many patients will have these symptoms both before and after anti-reflux surgery. In a study from our institution, diarrhea was present in 14% of patients before surgery and 29% after. Other symptoms included bloating (3% preoperative, 19% postoperative), constipation (15 and 18%, respectively), and abdominal pain (2 and 8%, respectively) (Figure 9.1).39 Flatulence has been reported in 12-88% of patients after anti-reflux surgery.40,41 It has been suggested that this flatulence is attributable to the patient's inability to belch and subsequent passage of more gas into and then through the gastrointestinal tract.42 Most of these studies are retrospective and at risk for recall bias, because many only surveyed patients after surgery and asked them to recall how they were before the surgery. In general, the suggested causes for increased flatulence after

Anti Reflux Procedure
Figure 9.1. Prevalence (%) of bowel symptoms before and after anti-reflux surgery in 84 patients. (Adapted from Klaus et al.39)

anti-reflux surgery are the same as those listed for gas bloat. This is a very common symptom in the general population and care must be taken not to inappropriately attribute it to the effect of surgery.

If diarrhea develops after fundoplication, it tends to be low volume and occur after meals, but can be explosive at times. Postfundoplica-tion diarrhea has been attributed to dumping syndrome, vagus nerve injury with subsequent bacteria overgrowth, and to exacerbation of underlying IBS. The loss of the fundus accelerates gastric emptying in some patients, which may result in overloading the small intestine's ability to handle the bolus. Classical dumping syndrome has been reported after anti-reflux surgery, particularly in infants and children.43 A small series found evidence of dumping (by glucose tolerance test or gastric emptying study) in 15 of 50 (30%) infants after anti-reflux surgery.44 In addition to classical dumping, rapid gastric emptying may result in diarrhea attributed to overloading the small bowel with poorly digested, high osmotic material. Impairment in vagus nerve function can cause diarrhea by changing the body's ability to clear bacteria and maintain bile acid homeostasis because of alterations in small bowel motil-ity.45,46 Attributing diarrhea to a specific etiology can be quite difficult. For example, our center reported a case of a patient with severe diarrhea believed to be the result of vagus nerve injury (documented by an abnormal pancreatic polypeptide response to a sham meal).47 In a subsequent, larger study in which the test was performed before and after surgery, there was very little correlation between the results of the pancreatic polypeptide test and postoperative diarrhea48 (Figure 9.2).

There is considerable overlap between GERD (particularly nonerosive disease) and IBS.49 Nonulcer dyspepsia also overlaps with heartburn and it is possible that some patients may have been operated on for reflux when their pre-operative symptom was actually more attributable to nonulcer dyspepsia.50 This diagnostic confusion has been exacerbated by the tendency to use response to PPI therapy as a diagnostic test for GERD. This approach actually has poor sensitivity51 and we believe that pathologic reflux should be documented before considering surgery in any patient. Therefore, a positive "PPI test" should not be considered sufficient

SYMPTOMS AFTER ANTI-REFLUX SURGERY: EVERYTHING IS NOT ALWAYS CAUSED BY SURGERY

SYMPTOMS AFTER ANTI-REFLUX SURGERY: EVERYTHING IS NOT ALWAYS CAUSED BY SURGERY

Anti Reflux Surgery

Figure 9.2. Lack of association between abnormal vagus nerve function as measured by the meal-stimulated pancreatic polypeptide (PP) test and development of new lower gastrointestinal symptoms. In this study,6 of 15 patients developed new lower gastrointestinal symptoms after anti-reflux surgery and the PP test was only abnormal in half of those 6. In contrast, 9 patients either had no new symptoms or an improvement in their symptoms, yet 5 of those 9 also had an abnormal PP test of vagus function. (Adapted from DeVault et al.48)

Figure 9.2. Lack of association between abnormal vagus nerve function as measured by the meal-stimulated pancreatic polypeptide (PP) test and development of new lower gastrointestinal symptoms. In this study,6 of 15 patients developed new lower gastrointestinal symptoms after anti-reflux surgery and the PP test was only abnormal in half of those 6. In contrast, 9 patients either had no new symptoms or an improvement in their symptoms, yet 5 of those 9 also had an abnormal PP test of vagus function. (Adapted from DeVault et al.48)

documentation of GERD before surgery. In addition, patients have been documented to "migrate" from one functional symptom (heartburn for example) to others (IBS). This was highlighted by a recent retrospective study of 155 patients finding that a coexisting diagnosis of a nonreflux functional bowel disorder (usually IBS or dyspepsia) more than doubled the risk of a loosely defined "poor outcome" after anti-reflux surgery.52 When one is confronted with a patient with postoperative bowel symptoms, determining whether their symptom complex was really present before surgery is difficult and perhaps impossible. Ideally, the same physician should evaluate the patient before and after the surgery, but this is often not practical in our health care system.

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