Month: November 2020

With the national obesity epidemic, bariatric surgery is commonly performed. Patients who have undergone bariatric surgery require lifelong vitamin and mineral supplementation. Consultation with a GI specialist regarding malabsorption of vitamins and minerals will prevent the development of these complications.

After Roux-en-Y gastric bypass (RYGB), a long portion of the proximal small bowel is bypassed. This portion of the small bowel is critical in absorbing iron, multiple vitamins, and essential minerals. Calcium, magnesium, iron, zinc, folic acid, and copper are absorbed in this portion of the small bowel. Without supplementation, vitamin and mineral deficiencies will occur. Many patients are told to take one or two multivitamins a day.

Most of these supplements do not contain enough iron nor calcium, such as selenium, zinc chromium, and copper. Nutritional supplements need to be tailored to the individual patient’s nutritional requirements. A GI MD can monitor this.

After sleeve gastrectomy, the recommendations for multivitamin and mineral supplementations are generally the same. After either type of gastric surgery, a nutritional assessment is recommended every six months for the first year. Laboratory testing will be needed annually after that. A GI specialist can manage this assessment.

Below is a summary of the recommended vitamin and mineral supplements following surgery. Also listed are the disease complications associated with the specific deficiency.

  Vitamins and Minerals

 It is crucial that, after weight loss surgery, you ensure you’re getting the necessary vitamins and minerals. Nutritional deficiencies will most likely occur as you are eating less. This means you may not be getting the necessary vitamins and minerals from your food intake. You should have your labs checked regularly.

Below you will find the recommended supplements for patients of weight loss surgery. However, make sure you always consult your doctor as your individual needs may differ.

  Multivitamin

Take a high-potency, chewable multivitamin and mineral supplement containing a minimum of 18 mg of iron, 400 mcg of folic acid. Selenium, copper, and zinc daily. Brands that contain this formula include Centrum adult chewable multivitamins. Take two tablets daily until at least three months after your surgery, and then one tablet daily for life.

  Calcium

Take 1,200 to 2,000 mg daily to prevent calcium deficiency and bone disease. To enhance absorption, take the calcium supplement as two to three divided doses throughout the day. For example, take 500 to 600 mg tablets three times a day. Calcium citrate is the preferred form of calcium.

  Vitamin D

Take 800 to 3,000 international units (IUs) of vitamin D daily. This total amount should be taken as 400 to 500 international units (IUs) twice a day with your calcium supplement. If you prefer, you can take a combination of calcium-vitamin D supplement as long as it contains the proper dosages to avoid taking multiple pills.

  Vitamin B12

Take 500 mcg of vitamin B daily. This can be taken as a tablet or a liquid under the tongue. Remember, whole pills must be crushed. You may need additional folic acid or iron supplements, particularly if you are a female and still menstruating.

You should never take non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, Advil, Motrin, Aleve, Vioxx, Naprosyn, or Celebrex. This is because these medications increase the risk of developing ulcers. 

Ulcers become increasingly difficult to diagnose and treat following bariatric surgery. Always consult with your doctor or pharmacist before starting a new medication.

Trouble with constipation is common among patients of bariatric surgery. Should this present a problem, there are a few things that might help; Benefiber being one of those things. Two teaspoons of Benefiber powder can be mixed into hot or cold drinks. You can also take Benefiber in the form of a caplet or chewable pill. Metamucil could also help. 

Helicobacter Pylori Infection (H Pylori) is the most prevalent chronic bacterial infection. This infection is associated with chronic stomach inflammation, stomach and duodenal ulceration, and stomach atrophy. Having this infection increases your risk of developing gastric cancer and gastric lymphoma (M A L T).

H pylori is often diagnosed by upper endoscopy by a GI specialist for evaluation of upper abdominal pain. H pylori can cause gastric and duodenal ulcers. The eradication of the infection will decrease the possibility of recurrent ulcers. In patients taking nonsteroidal anti-inflammatory medications, H pylori’s presence increases the chance of ulceration and intestinal bleeding. 

H pylori can also cause chronic gastritis, which is a surface inflammation of the stomach. Chronic gastritis can result in atrophic gastritis, which can lead to iron malabsorption and anemia. Atrophic gastritis can lead to the development of gastric cancer. If a patient has a family history of gastric cancer, screening for H Pylori infection is recommended. A low grade gastric mucosal lymphoma ( M A L T) can result from such an infection. Often the only treatment needed is the eradication of the infection. Limited evidence suggests that eradication of H pylori improves platelet count in some patients with idiopathic thrombocytopenic purpura (IT). 

If you are experiencing upper abdominal pain, see a GI MD. Depending on the circumstance, an H pylori breath test can be ordered. Treatment will be administered if the test result is positive. If the pain is accompanied by GI bleeding, anemia, or weight loss, an upper endoscopy (EGD) by a GI specialist will be necessary. It may also be needed if you have a family history of stomach cancer.

Antibiotics with a proton pump inhibitor are used to treat H pylori. Since the bacteria are now resistant to multiple antibiotics, this can be exceedingly difficult and require multiple regimens prescribed by a gastroenterologist. A new drug regimen, Talicia, which I helped research, is 90% effective in eradication. 

Confirmation of cure is essential. The conventional treatment is only 60%-70% effective. This testing is usually done by H pylori breath test at least two months after completing treatment. Once the cure is confirmed, H pylori can not reoccur. If treatment is not successful, then a continued infection can lead to an increased risk of gastric cancer. A GI specialist can monitor this process.

Most cases of acute diarrhea are mild and in short duration. These cases are most often viral and require no specific treatment. However, diarrhea accompanied by high fever, bloody stool, and severe pain could cause a bacterial infection. Because of this, an evaluation by a GI specialist is needed. Salmonella, Shigella, and Campylobacter are the most common types of infections. If a patient has recently undergone treatment with antibiotics, they may have an increased chance of suffering from an infection by C. Difficile. This is a type of bacteria that can cause severe acute colitis

History of recent travel, antibiotic exposure, duration, food intake, and animal exposure are 

important clues in determining the possible causes of diarrhea. Laboratory evaluation to screen for dehydration and kidney dysfunction is an essential part of the evaluation. 

If severe diarrhea occurs along with dehydration, severe abdominal pain, the passage of 

bloody stool, or fever, further evaluation should be ordered. Stool multiplex molecular panel will screen for multiple different bacterial, parasitic, and viral infections. Consultation with a GI specialist can facilitate this testing.  

Regardless of the cause, management of acute diarrhea starts with fluid repletion. Diluted fruit juices with saltine crackers, broths, and soup may meet fluid requirements. The fluid should contain sugar, salt, and water. However, sports drinks that are used to replace sweat are not particularly useful.  

Since a viral infection causes most cases of acute diarrhea, antibiotics are not sufficient. 

Indications for antibiotic treatment include high fever, dehydration, blood in the stool, and 

immunocompromised patients. Consultation with a GI specialist can determine appropriate 

therapy. 

Chron’s Disease (CD) is a type of inflammatory bowel disease characterized by transmural inflammation of the bowel. Although CD can involve any segment of the GI tract, the ileum and cecum’s involvement is most common. If this occurs, the patient’s symptoms would include right lower abdominal pain, fever, and watery diarrhea. Fistula formation caused by abscesses often complicates CD. Crohn’s disease may also present more subtle symptoms such as mild diarrhea, crampy abdominal pain, and weight loss. 

These symptoms are often thought to be due to irritable bowel syndrome, and months may pass before the diagnosis of CD is made. Because of the variability of Crohn’s involvement, multiple symptoms such as nausea, vomiting, fatigue, and fever may occur. These symptoms should be addressed by a GI specialist with expertise in diagnosing CD.

With the introduction of multiple biologic agents, the treatment of CD has greatly improved. Prior to their introduction, treatment was limited to corticosteroids and immune modulators, which were often ineffective. The resulting clinical scenario was multiple operations with resulting complications, including malabsorption, chronic abdominal pain, anemia, and malnutrition. 

After a thorough investigation and discussion with a GI MD who treats Crohn’s disease, a treatment plan tailored to the patient’s specific needs can be started. The success rate of any biologic achieving endoscopic remission is 30% to 40%. Because of the number of biologics currently available, multiple options exist. A GI specialist can monitor this.