Eat Happy!

Eat Happy!


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Wednesday, January 23, 2013

Before-During-After Air

OK tubie momma engineers....... I have a question........ or more likely........... a challenge!!

Ian has a lot of trouble with gas/air in his belly. It happens all the time. It happens before, during, and after meals. We always make sure to vent him before his meals. Sometimes there is air, and sometimes there is nothing. If there is nothing, this does not mean there won’t be during or after his meals. So......... the trouble comes on how we can vent air out of his belly during and after meals. This sounds like a simply question, but it is far from simplistic.

Farrell Valve Bags are designed to decompress the belly while eating. They allow food, air, and gastric contents to follow out of the body when the stomach is overfilled. it also allows the contents to flow back in as the body allows. The trouble with this is *everything* flows back in: food, gastric content (desired) and the air (undesired).

Farrell Valve Bag

The way the Farrell Valve Bags are designed, there is nothing in the bag before it is used. There is a small one-way valve at the top right of the bag. As contents flow into the bag, it is almost as if a vacuum is created. While the air is allowed to escape at the top of the bag, there is not enough pressure to push the air all the way through the tubing. With food in the tube as well, the pressure of the belly decompressing is not strong enough for the air to pass the food and be released within the bag...... allowing the food to flow back in. As a child or adult who *needs* decompression in the first place, the intake of air along with the acceptance of food is a bad idea.

Farrell Valve Bag

........... essentially, if the air cannot be pushed all the way through the tubing, as the food flows back in....... everything in the tubing does, including the air.

But of course Ian has extenuating circumstance! To make matters worse, he has.......

***** Fundoplication:

Ian has a fundoplication. A fundo is when the top of the stomach (fundus) is pulled upward and wrapped around the base of the esophagus from behind. It is then stitched to the esophagus itself in a various numbers of ways. Ian has a three-quarter wrap, called a Toupet. Many fundos are Nissens, a full 360 degree wrap. Either way, it is very difficult for stomach contents to escape....... which is the purpose of the fundo! Fundos are done in cases of severe reflux when the muscles and lower-esophageal-sphincter is unable to keep contents down. The wrap helps generate that ability because as the stomach contracts to reflux or vomit, the fundo contracts around the base of the stomach, restricting the release of contents into the throat.

***** Delayed Gastric Emptying:

Ian also has delayed gastric emptying (DGE). Many many many times, it is a bad idea to do a fundo if someone has DGE. It creates a “pressure-cooker” type stomach. With no where for contents to escape, everything must wait and be sent through the intestines. Ian can burp or vomit, but he REALLY has to want it, which only happens when he has a stomach bug. Often times, DGE patients will have a fundo with a pyloroplasty. A pyloroplasty is when the pylorus, bottom opening of the stomach is opened more than its original position. It can be cut or dilated. This allows for quicker emptying of the stomach contents when it is overfilled and cannot escape through the fundus. This provides a lot of relief for patients.

Ian's Gastric Emptying Scan 10.2011: He somehow fell asleep!

***** Post-Prandial Hypoglycemia:

Thirdly, Ian has post-prandial hypoglycemia, known as late-dumping syndrome. What happens when a fundo is performed doesn’t only make the fundus-esophageal junction stronger, it changes the shape of the stomach. As the top of the stomach is pulled upward and stretched, it elongates the stomach. In addition to that, the stomach is now smaller because a portion has been used to create the wrap. The stomach is anatomically designed the way it needs to be to push food along. When the stomach changes shape, so does the way it empties. The contractions that push the food along through the stomach are called peristalsis. Peristalsis is not performed the same way after a fundo. 

Messing with the way the stomach empties can cause a multitude of other issues. Ian’s stomach empties slowly, the DGE......... but, when it *does* empty, the food flies out of the stomach very quickly, aka: dumping. As this happens, the blood is flooded with glucose. When glucose enters the bloodstream, insulin is released to take up the unneeded portion and stores it for later. There is something that happens with dumping that signals a LARGE amount of insulin to be released. This “something” is unknown. Ultimately, more insulin is released than needed. The blood runs out of glucose before it runs out of insulin. This creates hypoglycemia (low blood sugar). This hypoglycemia causes sweating, nausea, vomiting. 

The higher the carbohydrate load, the worse the response. Using more complex carbs helps delay the digestion process and postpose glucose drops. When the large amount of insulin is released, it does not happen all at once. It continues to do this in order to “take-care-of” all the glucose in the bloodstream. The body responds to the administration of glucose, raising the blood sugar, and restoring the balance. 

***** Hypersensitive Vagal Response: 

The vagal response is the one that can bring on gagging and retching. When the vagus nerve is *triggered* by a stimulus (vomiting, food or mucus in the throat, bearing down for a bowel movement) gagging and retching occur. Vomiting can be an end result. Ian’s vagus nerve is very sensitive and can be triggered by lying down after a meal. It is hypersensitive from the fundo. The nerve runs through the area and is *disrupted* during surgery.

Vagus nerve passing through the top of the stomach

When the fundo contracts to keep in stomach contents, it irritates the vagus nerve. As the food sloshes around and near his esophagus, he begins to retch and gag, strongly! It is also triggered by sitting up too quickly after a meal, as the stomach is compressed when it is full. Because of this, we are often unable to lie Ian down during a meal to vent him. We certainly are not able to lie him down after a meal, with a full belly, for venting. 

Here are a few images of the vagus nerve and its pathway through the throat and innervation of the stomach. There is much more detail than what is needed.... but it shows the placement, the emetic (vomit) reflex that is triggered, and swallowing process.

Vagus nerve passing from the brain, through the neck, and into the stomach

How the Vagus nerve affect the upper GI tract

Image of the swallowing phases, which can irritate the Vagus nerve

An *extremely* over-exagerated picture!!!
However, it does show that the emetic (vomiting) reflex in the brain is directly linked to the Vagus nerve.
The cytotoxic chemo is irrelevant to our discussion.  "Vagal afferents" means "sensing."



As a recap, Ian has a lot of air in his belly before, during, and after meals. He is unable to release air through burping because of the fundo. His belly also doesn’t emptying properly due to DGE. He holds food in his stomach for a long time and releases it all at once, creating dumping and hypoglycemia...... all of these interacting with a hyperactive Vagus nerve.  Ian’s hypoglycemia and dumping are *relieved* by complex carbs and slow feedings. Throughout the entire digestion process, air is created through the stomach and intestines. THIS is the air we need to escape during and after his meals. Farrell Valve Bags are insufficient in allowing the air to escape.

Here is the challenge....... We need a way for this air to escape, other than venting him before, multiple times during, and after his meals, allowing for the free flow of food into the stomach, while feeding him slowly by his feeding pump.

Historical attempts include using the Farrell Valve Bags and periodic venting. We tried placing the bag at higher and lower levels to try and mess with gravity and pressure. I even cut a hole in the bag in different sizes and at various levels in hopes of relieving some pressure within the bag. The air was still unable to escape. Then I tried rearranging the tubing so that gravity pulled in multiple ways....... still no luck. After an hour in the bathroom with a feeding bag, backpack, tubing, Farrell Valve Bag, pump, syringes, and some blue food coloring in water for visual, I was unsuccessful...... and messy. Thankfully I had the end of the tubing extension in the bathtub to minimize the mess.

Ideally, it would be great if could somehow rig a 60mL syringe in a manner that the food would neither spill out nor be overflowed from too much decompression. It might be unrealistic to expect this result with all of Ian’s issues........ including the one that I cannot get a two year old to sit and do something while he eats....... I’ll keep trying on that one!

60 mL syringe attached to some tubing for venting

Without an evolutionary idea, we will continue taking our chances with lying him down before, during, and after meals for periodic venting.

OK creative mommies........ GO!

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