Eat Happy!

Eat Happy!

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Friday, May 11, 2012

Nissen Fundoplication Complications

Recently, Ian has been missing some of his Benadryl dosages throughout the day.  This was purely by accident.  Although, since missing them, he does not seem to be effected.  Upon making this discovery, we contacted Ian’ surgeon at CHOP to inquire about the potential for weaning the medication.
As you will recall, Ian has been taking the Benadryl to suppress the vagal response.  As I take myself back to Ian’s initial CHOP visit for the retching, I remember him saying at the GERD clinic that Ian had a strong vagal affluence.  What I did not know if this is a potential side effect from the Nissen surgery.  I discover this tonight by accident.
We were told by the surgeon that instead of giving Ian 4mls of Benadryl every 6 hours, to try only giving it to him at night before bedtime and see how he responds.  I decided, because I am the analytical person that I am, to research how Benadryl exactly helps with vagal response.  I recall doing this back in December with little popping up.  I stumbled across some information and articles relating to 5HT-3 receptors and antihistamines but nothing showed strong correlations.
Vagus Sensitivities and Gastric Surgeries
I decided upon a whim to research Benadryl (diphenhydramine) with Nissen, emetic reflex (vomit reflex), and vagal response search words.  What began appearing was a little disturbing.  The hightened response is very strongly linked with gastric surgery, laparoscopic Nissens in particular.  I remember my uncle, also a surgeon who has performed this on adults, speaking about this pre-surgery.  He mentioned retching was a potential side effect following Nissens... I was not aware it coordinated with vagal responses and nerve sensitivities... especially since Ian had been retching in the productive forming of vomiting prior to surgery.
Initially is seemed as though the retching was simply unproductive vomiting... meaning he was doing the same thing as before... but the food was staying in this time.  Little did we know, the reasons for the retching were completely separate from the reasons for the vomiting.  Ian’s previsouly vomiting was from GERD, and the current vomiting urge, shown in the retching, was from the vagus nerve.
Animal research has also been completed to help understand this connection.
Nissen-type fundoplication and its effects on the emetic reflex and gastric motility in the ferret
Hypoglycemia
I have listed a few of these links here and will be adding them to a section identifying Nissen Fundoplication Potential Complications.  Another complication of course is the previously discussed post-prandial hypoglycemia.  There is a whole section of resources dedicated to this complication since Ian has such trouble.  This complication has to do with escalated gastric emptying either early, or late after eating.  Early is 30-60 minutes after eating and late is 90+ minutes after.
gastric dumping
Dumping syndrome: a common problem following Nissen fundoplication in young children.
Dumping syndrome after Nissen fundoplication.
Dumping syndrome following Nissen's fundoplication: a cause for refusal to feed.
http://www.ncbi.nlm.nih.gov/pubmed/6427440



Dumping Syndrome Following Nissen Fundoplication, Diagnosis, and Treatment

journals.lww.com/jpgn/fulltext/1996/10000/dumping_syndrome_following_nissen_fundoplication,.6.aspx

One of the latter interested me since Ian has had such refusal to eat since the surgery.  In combination with his adverse memories of eating a vomiting, this may play a part in why he no longer wants to eat.  Due to the effect on the vagus nerve, stomach, and intestines from the gastric surgery, eating may no longer an enjoyable and desirable behavior.  With therapy and specialized diets and routines, it seems as though this can also be a managed side effect for most.

Diarrhea
Since I seemed to be on a role here, I was intrigued.  I started looking for articles including gastric complications and Nissen Fundoplications.  I noticed that there were others.  Of course, as we already knew, vomiting from vagal sensitivities was common.  Another “ah-ha” moment when I stumbled across the word “diarrhea!”  Well, if you haven’t caught some of the earlier blogs....... Ian has been struggling with pretty persistent and sometimes severe diarrhea.
No one ever mentioned this being potentially originating, or escalated form the surgery.  As I read further, since the vagus nerve innervates the stomach, causing the potential for the previously mentioned complications... it also contributes to bowel function.  This happens in multiple ways.
First, since the gastric emptying is escalated causing the dumping syndrome, food enters the bowel and moves through much faster than normal, curtailing the amount of time in the large intestines used to absorb water.
Secondly, the rise in glucose from the dumping syndrome causes extremely large amounts of insulin to be released.  Late dumping syndrome is correlated with carbohydrate digestion (as opposed to early dumping syndrome correlated with fat digestion).  Since carbohydrates are not digested and absorbed properly in the small intestines because of unstable glucose levels... things do not arrive properly into the bowel and may be partially undigested.  Larger, undigested particles will draw water and can created looser stools.
Thirdly, and most apparent, the vagus nerve innervates the intestines and first 2/3rds of the colon.  If the vagus nerve is sensitized by gastric surgery, such as Nissen Fundoplications, then potential side effects could appear as diarrhea.
All of this concerning diarrhea has been unknown to us until tonight.  I feel that CHOP never mentioned it specifically because it did not seem to be causing Ian severe issues with weight and hydration when it came to the diarrhea.  but you know me, I am always looking for explanations.  With Ian, sometimes they are the only ones I get!

Dysphagia



Oral Dysphagia is another complication that can follow Nissen Fundoplications.  This symptom can also occur simply in the rpesence of GERD, regardless of gastric surgeries.  Simply stated, dysphagia is difficulty in swallowing.
These are some resources available to inquire about dysphagia.  Most of them center around gastric surgery complications in pediatric patients.
The effects and efficacy of antireflux surgery in children with gastroesophageal reflux disease: a systematic review.
The evolution and long-term results of laparoscopic antireflux surgery for the treatment of gastroesophageal reflux disease
A review of laparoscopic Nissen fundoplication in children weighing less than 5 kg






Treatments
Treatments are varied and numerous.  Although, it does seem as though these are chronic and sometimes permanent side effects.  However, it has been shown that with careful monitoring, they can be very well managed.
*** An off-label and unconventional treatment for the gastric dumping is corn starch.  The corn starch delays the time the food remains in the intestines and the bowel.... allowing for a more stable blood glucose level, and decreasing the risk for diarrhea.
cornstarch for post-prandial hypoglycemia
cornstarch for hypoglycemia
*** Another treatment, as Ian has been taking, is an anti-emetic medication that suppresses vagus nerve sensitivities with nausea.  Anti-emetics work in a few different ways.  They can either block signals in the vomiting center of the brain in the medulla oblongata directly, block receptors in the stomach and intestines that trigger nausea in the brain, and/or act directly on the stomach by increasing the rate at which it empties and moves food through the bowels.  These reasons are why the Benadryl helps with nausea.  This too, is an off-label use of a medication.
Vagus nerve issues can arise from sensitivities from gastric surgeries, or from vagus nerve damage during surgery.  Nerve damage is rare and is difficult to prove since similar side effects can occur without damage.
Other Resources
Intractable hiccup: an odd complication after laparoscopic fundoplication for gastroesophageal reflux disease.
Motor and sensory function of the proximal stomach in reflux disease and after laparoscopic Nissen fundoplication.
Postoperative Gastrointestinal Complaints After Laparoscopic Nissen Fundoplication
Nissen Fundoplication and Gastrointestinal-Related Complications: A Guide for the Primary Care Physician
[Modifications of the glucose curves and gastric voiding of children with Dumping syndrome after laparoscopic Nissen surgery].
http://www.ncbi.nlm.nih.gov/pubmed/21520550


*****Please also see my post concerning Blenderized Diets as treatment for post Nissen Fundoplication complications

3 comments:

  1. I have been reading your blog and I am sitting here stunned... my son started gagging and retching following his nissen/g tube placement. The docs are "clueless" telling me his tummy is too full and I keep telling them NO it's not. The info you have on the connection between the vagus nerve - gagging following a nissen sounds just like my son. Also, he slowly stopped breast feeding post op and is now 100% tube fed, combo of breast milk and BD. We are starting with a new OT and PT next week, I'll be sharing this info with them. I'm literally in tears thinking what did I let them do to my baby???? When I first tried giving him solids by mouth he ate pretty well for the first 2 days and then refused and has refused ever since. It's like he WANTED to do it but obviously it's extremely uncomfortable for him and I'm now positive that this is all related to the nissen. Your blog is SO comprehensive I'm so impressed. Would it be alright if I friended you on FB and possibly I could message you privately? Thank you for doing so much research, I can't tell you how helpful this is!!

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  2. Sure! Glad to help. Contact me anytime!!!!! :)

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  3. My son is 21 months old and had a Nissen at 5 weeks. He's had daily gagging, retching and vomiting ever since despite everything we've tried, including a j-tube. What you've written is extremely helpful as I try to figure out how to help him! Thank you!

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