Mean time to presentation 6-7 weeks
Nausea, vomiting, early satiety, food intolerances, abdominal pain Endoscopic balloon dilatation, repeat dilatation required in 17% of cases dietary indiscretions and vomiting associated with bulimia are ruled out, a stomal stricture at the gastrojejunal anastomosis should be considered. The reported prevalence of stricture ranges from 2.8 percent-7 percent.14,15 The presenting complaint is vomiting and postprandial pain in the gastric pouch (Table 8.3). A barium swallow often detects narrowing at the gastrojejunal anastomosis, and a referral to a gastroenterologist for endoscopic dilatation should be made. Marginal ulcers at the anastomosis should be searched for. A decision to insert a nasojejunal feeding tube at the time of endoscopy should be considered depending on the degree and rate of weight loss.
Dumping syndrome occurs in approximately 50 percent of patients after RYGB. The same phenomenon does not appear to happen after the Lap-Band procedure. It is characterized by symptoms of nausea, shaking, diaphoresis, and diarrhea immediately after eating high-glucose containing foods. It is considered a positive outcome after RYGB, especially in sweet eaters, since it results in food aversion to sweet eating. Patients who experience these symptoms should be advised to avoid the foods that produce them.
After gastric-bypass surgery, there are psychological changes associated with the change in eating patterns, and these changes can cause significant dysfunction. It is well-established that extreme weight loss results in symptoms of psychopathol-ogy. In the classic Keys' studies in the 1950s, weight loss of 25 percent resulted in the development of lethargy, depression, and other psychopathology.16 Preopera-tively, patients with morbid obesity often use food for emotional reasons, and when they experience a small gastric pouch postoperatively, they often grieve the loss of food. Displaced emotions often result in somatization with symptoms of nausea and vomiting. It is important that physicians recognize the psychological aspect of the loss of food after gastric-bypass surgery, and reassure patients that the symptoms are related to the small gastric-pouch size. Antidepressants often help to decrease the anxiety related to the grieving associated with the loss of food, although the use of antidepressants needs to be approached with an empathetic style.
Nutritional deficiencies are common after bariatric surgery for two reasons: inadequate dietary intake and the surgical procedure itself. The lack of intrinsic factor results in inability to absorb vitamin B12. Intramuscular injections of 1000 ^g of Vitamin B12 should be given every six months for life. Long-term nutritional deficiencies are common, especially if dietary variety is lacking and vitamin supplements are not ingested regularly. After RYGB, the lack of acid in the gastric pouch results in poor absorption of iron, and iron deficiency has been described in up to 15 percent of patients. It is important to emphasize the importance of a daily multivitamin, in addition to adequate intake of dietary fruits and vegetables, in order to prevent nutritional deficiencies.
Clearly, a significant number of individuals go into obesity surgery with preexisting eating-disordered behavior. To maintain the weight loss that typically follows surgery, they have to change their eating patterns dramatically. General normalization of eating behavior has been reported characterized by fewer meals, less food consumed at each meal, less eating between meals, and less eating in response to strong emotions.1719 Severe binge eating becomes virtually impossible following gastric bypass due to the severely restricted stomach. Despite this, patients with a preexisting eating disorder continue to have disordered-eating patterns.
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