REFLUX - re-post

Re-posted for all the people I see struggling here with reflux!
I've not had a chance to post regularly here for a good while, I'm afraid. I've had a major move, and my very elderly mother is quite ill and will not be getting bette and I'm her Case Manager 24/7, so I really have my hands full..not to mention a new formal band position, and my ongoing daily work with my own band education forums. I'll pop in here when I can, though.
Cheers to everyone! - Sandy

Reflux - Teaching Module

Reflux is always a serious problem in a Bandster.

We should never just cover up symptoms of reflux. We must find and
correct the REASON for it. Reflux before banding is very different
than reflux after banding - different causes, different treatment,
and different problems with it.

Reflux - why we must avoid it


What is Reflux?

Reflux (GERD or Gastro-Esophageal Reflux Disease) is caustic stomach
acid that comes back up into the esophagus, where it does not belong.
The stomach has a protective lining that prevents this stomach acid
from causing stomach damage, but no other tissue in the body has this
protection. Any acid that contacts areas other than the stomach
tissues easily causes damage.

Reflux causes ear infections, sinus infections, throat infections,
new or worsening asthma, tooth decay, and if we inhale it at night
when we wake up coughing and choking, it can cause a very bad
aspiration pneumonia. Untreated reflux can also cause esophageal
cancer, which is badly increasing in North America and elsewhere.


What causes Reflux (GERD) before banding?

Many obese people have a hiatal hernia which causes reflux before
banding. Most obese people also have a poorly-functioning valve at the top of
the stomach,
called the LES (Lower Esophageal Sphincter) that is damaged from
abdominal fat back-pressure. The valve does not close correctly,
allowing stomach acid to back up into the esophagus. Many need
surgery to repair the hernia, and/or acid-reducers to try to minimize
the damage. Being very obese and having a hiatal hernia and it's
associated health problems is one of the several conditions that is
considered a "Co-morbidity" and a reason to GET Band surgery.(NOT a
reason it cannot be done)

With Band surgery, most of these hiatal hernias need to be
repaired, since the hiatal hernia is just where the band must go.
They are so routinely repaired that the Band surgeons sometimes don't
even tell us we had a hernia, but I believe we should know. It can
make recovery bit more painful and lengthy. With known reflux before
surgery, many band surgeons want a pre-op upper GI to evaluate the
size of the hernia so they can better plan surgery an the repair.

Of those who had a hiatal hernia causing reflux before band surgery,
about 76% are completely cured with Band Surgery. Another 14% see a
huge improvement. A few see only moderate relief and may need to continue
long-term acid-reducers.





What about reflux (GERD) AFTER banding?

Reflux STARTING AFTER band surgery is another thing entirely, and
with very different causes. Bandster reflux must be avoided., as it
is especially harmful in a number of ways.

When reflux starts after a new fill, it almost always means the fill
is TOO TIGHT and needs some fill removed. If we get back in very
quickly before swelling and damage occurs, as little as 0.2 cc or so
out can relieve the reflux and likely will not affect the effect of the new
fill.

It is not enough to simply cover up
reflux symptoms with medication - the CAUSE of the reflux must be
found and fixed.

When new reflux starts that is NOT associated with a new fill, it is
a sign of possible problems that must be checked out if it persists.
First, though, be sure you're following the "Anti-reflux Guidelines
for Bandsters", below. It's easy to fall back into old habits that promote
reflux.

If new reflux persists despite these
measures, we must consider a Band slip or pouch/esophagus dilation as the cause
and see our docs quickly for a fluoro evaluation and treatment. Those who
are more than a year out are especially prone to pouch dilations, if they
are not careful to never eat more than 1-1.5 cups of food - whether
the band stops them or not.

ANY Bandster with a new ear infection, sinus infection, new or
worsening asthma, ongoing dental problems (especially in the back teeth) or
pneumonia must consider reflux as the cause and
discuss this possibility with family and band docs. Family docs
often don't know about this connection, sadly. We must help them learn.


What are symptoms of reflux?

1. Chest burning or pain

2. Acid laryngitis. This is condition that includes hoarseness, dry
cough (especially at night) , the sensation of having a lump in the
throat, and the need to
repeatedly clear the throat.

3. Trouble swallowing (dysphagia). In severe cases, patients may even
choke or food may become trapped in the esophagus, causing severe
chest pain. This may indicate a temporary spasm that narrows the
tube, or it could also be an indication of serious esophageal damage
or abnormalities.

4.Chronic sore throat.





5.Persistent hiccups or burping .

6. Coughing and Respiratory Symptoms. Asthmatic symptoms like
coughing and wheezing may occur. In fact, in one study, GERD alone
accounted for 41.1% of cases of chronic cough in nonsmoking patients.
The incidence was even higher when GERD and asthma were combined.
ANY new or worsening asthma in a Bandster should be very suspicious of
reflux.

7. Chronic Nausea and Vomiting. Nausea that persists for weeks or
even months and is not attributable to a common cause of stomach
upset may be a symptom of acid reflux. In rare cases, vomiting can
occur as often as once a day. All other causes of chronic nausea and
vomiting should be ruled out, including ulcers, stomach cancer,
obstruction, and pancreas or gallbladder disorders.

8. Acid or metallic taste in the mouth

9. Chronic or persistent ear or sinus infections

10. ongoing dental problems, especially in the back lower molars


How can Bandsters prevent Reflux?

There are several standard things Bandsters should always do to
prevent reflux. Since some reflux cannot be felt and the damage is
still occurring, these preventative things should be very routine for
Bandsters, and start right after surgery. As we get tighter and
tighter with fills, the guidelines
will become even more important to heed.

1. Never keep a too-tight fill, thinking it will get better in time.
A too-tight fill is the #1 reason for ALL the serious band problems,
including reflux. There is just NEVER any good that results from too-
tight fill. The too-tight fill CAN loosen in time - because of a pouch or
esophagus dilation.

2. Don't eat solids within 2 hrs of bedtime. Anything in the pouch
or stomach when we lay flat encourages reflux. Some people may not be
able to eat solids within 3 hrs of bedtime.

3. If you nap during the day, use a recliner with your head higher
than your belly. The gravity helps keep stomach acid where it
belongs.

4. Take no meds within an hour of bedtime, even acid-reducers. Take them one
hour before laying flat, with a full glass of water to wash them completely
through the pouch.

5. ONE hour before bedtime, have a full glass of water (only).,
whether you take "bedtime" meds or not. This rinses out the pouch
and dilutes the night's stomach acid.

6. Stay very well hydrated, so the normal stomach acid is not
concentrated. For Bandsters, this means at least 80-100 oz a day of
no-calorie fluids. Adequate fluids are essential for Bandsters for
many other reasons too, including good weight loss, normal stools,
less variation in restriction, and much more. See the "Water" teaching
module in the files for more abou****er.

7. Some foods/fluids encourage reflux. If you have any reflux,
minimize or avoid them:
Coffee, caffeine, alcohol, chocolate, citrus (including tomatoes,
kiwi, strawberries, pineapple) , mint, greasy/spicy foods, onions,
garlic, all carbonation. A cup or two of normal-strength coffee in
the morning is OK for most people, especially if buffered with milk
or creamer, IF there is no burning or reflux.

8. Avoid clothes that are tight around the waist, as this increases
the stomach back-pressure that encourages reflux.

9.. Those with severe reflux who cannot get in at once for an unfill
should raise the head of their bed 6 inches on blocks or books, or
sleep in a recliner, until they see their docs. This will help
prevent the aspiration pneumonia common if acid is inhaled into the
lungs at night. Just adding extra pillows is NOT enough; the head of
the flat bed must be raised.

10. Avoid NSAID use for more than 2-3 days maximum. NSAIDs are known
to alter the protective lining of the stomach after about 3 days,
and then normal stomach acid can  damage the stomach. This alteration of the
protective lining CANNOT be prevented by simply washing the NSAID
thru the pouch, and is the major damage NSAIDs cause in Bandsters.
Some surgeons feel this is one of the causes of band erosions.

If you absolutely MUST take regular NSAIDs for things like severe arthritis,
also take an RX acid reducer, like Nexium or protonix. This helps protect the
stomach and prevent problems.

11. Some other medications also increase the risk of reflux. Look up
all meds you are asked to take, and request ones with the least risk
of reflux and stomach irritation. A good place to look up medications
is www.drugs.com . Take all meds correctly, as per special Bandster
needs. Remember that all meds should be liquid or cut up smaller than an
aspirin, and then followed by a full glass of fluid to wash the meds thru the pouch.


Acid-reducing Drugs

Some with persistent reflux despite all preventative measures must
take regular acid-reducers like nexium, prilosec, or protonix.
However, These are not without side effects, so should not be taken
routinely, unless really needed. Side-effects include nausea,
constipation,and diarrhea.

Many acid-reducers also interfere with medication and nutrient
absorption, and used longterm, can cause nerve damage and B-12
deficiencies. Some with kidney disease should not take these meds at all (and
many with diabetes have some degree of kidney disease even though
routine tests may not show it. By the time the routine kidney tests show a
problem, we have only about 10% kidney function left and are ready to require
dialysis)

Those with reflux and/or needing longtime acid-reducers should be taking the
special Bariatric Advantage Bandster Vitamins to avoid the common
deficiencies from these conditions or medications
(More about the Bandster vitamins in the "Vitamin" document in the files. )

Others on low-salt diets should also not take some acid-reducers.


As with ALL Bandster problems, PREVENTION of problems

is the key. It's much easier to prevent problems by following good
bandster habits, than to try to pick up the pieces after we are
already having trouble. With a good understanding of reflux and it's
causes in bandsters, it is easy to prevent it and all the problems it
causes.

c. Sandy Richards, BA, BSN, MN
Updated Feb 2010
Band Educator
at goal 6+ yrs

Sandy,
I want to thank you for this post. I was having problems with reflux after a fill. I talked to my doctor. He wasn't at all concerned. He told me that I shouldn't eat or drink near bed time and he didn't want to give me an infill because I was losing at a good pace. He told me that he would give me a slight infill when I got closer to my goal if I was still having problems. After a month of suffering, I called him back and talked to his nurse. I insisted on an small infill to help with all my problems. I wasn't sleeping at night because I kept choking on the reflux. She talked to the doctor and scheduled me for an infill the following day. When he was getting me ready for the infill he started to lecture me on the fact that if he gave me an infill, I would be able to eat more and wouldn't loose  as fast. I told him that I didn't care because I was miserable and tired!
To my great relief, the infill of .5cc's did the trick! The reflux is gone and I still have restriction! Thank God!

I am going to take a copy of this to him the next time I see him. He definitely needs an education on reflux and the band. I really don't care for him as a doctor. He always treats me like I don't know what I'm talking about. I always feel stupid after a visit to see him. I'm glad I stood up for myself and insisted on the unfil.
Thanks for educating us!

Shelli

Shelli, this is a horrible story. I'm SO sorry you had to go thru all this to get the care you needed. Reflux is ALWAYS dangerous if left untreated.  I'm surprised that you didn't end up with an aspiration pneumonia, or worse. It almost sounds as if he in a contest to have people lose as fast as possible - whether safely or not. This can NEVER be the case. SAFETY has to be the #1 goal - not fast weight loss.

After 7 yrs of this, I can't tell you how many people have lost their bands altogether from poor education and then trying to put up with unsafe things for the sake of "faster" loss.
.
The point is never to lose "at a good pace" - if it is because you are miserable and cannot eat!!!!  I have 2 very good friends who now have Barrett's esophagus (a pre-cancerous condition caused by reflux) after being told by their docs to "put up" with the reflux since they were losing OK. Barrett's esophagus  always requires band removal, so the person does not progress to full cancer. 
I can't imagine what some of these docs are thinking.. Clearly, they have not learned some important band needs and are not banded themselves so have NO practical experience. I wonder how fast he himself would have gotten in for a unfill if HE was the one up all night with reflux?  ugh. I bet yours is a mostly-bypass surgeon. They can have very little or NO specific band experience or training.
.
Do you have any options of band docs? If not, you're going to need to take the responsibility of educating yourself exceptionally well so you can get the care you need to stay safe and keep your stomach and band healthy.

Good for you, for standing up and insisting on what you know is right.

Sandy r 

OMG this is helpful. I posted recently that I have pretty significant reflux (no hernia I'm told) and was worried about my life post-band. I absolutely abhor the reflux now so I was terrified of what it'd be like after. Your post helped me a lot. I take nexim now, I imagine I'll continue to take it so that part of my life won't change.

It's so weird. I was all gung-ho on the band (and a little "blinkers on") until the day the doctor's assistant called and said they were concerned that my upper GI revealed significant reflux. Now all I seem to find are the band bashers and negative posts. It seems like lately I don't read many good things about it. It was like Murphy's law. My brain wouldn't allow me to see the good stuff.

But this? Much better. I feel much better... whew.

Thanks Sandy!  I ended up with an unfill today (after much weeping at work over the thought of losing my band).  A little disappointed in losing my restriction but that is definitely better than the alternative.  I can refill in 3 weeks.  I've learned my lesson!!!

Thanks Sandy! I lost all of my excess weight (105 lbs.) in six months which I know is way too fast. But I'm blessed in that I have never once since my surgery have had any reflux, ever thrown up, ever slimed, or even PB'd. But I also have very little restriction as I have only had two fills and kept the restriction to a minimum to avoid complications. But I also haven't used the band as the tool it can be and I'm actually going to go for a little more restriction now that I am on maintenance as I'm struggling a bit with my food choices. So I will be very careful as I get more restriction and I've printed this and will file it in my WLS folder for future reference. Nice to see you're posting again lately. You are such a great resource for us here.
Regards,
Matt

Thank you,Sandy and ditto to what the above posters have already said, you information is so helpful! I was recently diagnosed with both acid reflux & a small hernia which were discovered during the pre-op upper GI. I never even knew I had either problem, since I never felt uncomfortable. I am now on meds. until I get my band.
I am so happy to read positive posts regarding the band procedure and I am looking forward to my life after ... the band that is! lol

Sandy - Thanks so much for trying to educate us!  I had never experienced reflux until after my last fill.  Within 10 days I called the doctor requesting a slight unfill.  I had trouble sleeping and experienced slight reflux probably 4-5 times in that 10 days.  Never during the day.  The doctor's office was surprised I'd ask for an unfill as I had lost 7 pounds in those 10 days.  He said his normal practice is to remove 1 cc and let the esophogus heal before doing another fill.  My previous fill had been .5 cc.  After much pleading he agreed to remove .4 if I promised to call if the reflux continued.  I had no further problems.  Now, in your opinion, does this mean no more fills?  Is the reflux destined to return with a fill?? Thanks Sandy! - Hugs, Pat

 

Pat, it's just unbelievable to me that any doc or fill practitioner would give  people a fill and send them home, with no education and written information about signs and symptoms of fill problems. Very unethical and immoral, IMO. How are we to learn if they don't educate us? Get into trouble first, and then have to crawl in and pick up the pieces? 

You're all lucky to have the time and access to an education and support site like this one, but what about the high percentage of bandsters that do not ? Are they supposed to be on their own in this tricky Band journey? This lack of education is a big reason why the band general stats are not very good, and why so many people get into trouble.

It's also why I strongly recommend choosing ONLY a nearby band surgeon, and never going to another country like Mexico . There just CANNOT be adequate followup - and it's the post-op education and followup for years that determines our success - NOT the very simple band surgery itself.

IMO, it's really essential to choose only a Band doc with excellent experience and track record. Far too many (again, IMO) do mostly bypasses and a few bands, and are neither excited about the band nor well-educated in helping/teaching/supporting their Band patients being successful. 

If someone has lost 7# in 10 days - that is a clear sign of trouble (too tight). It's hard to believe he thought that was OK, and that you should be delighted with the 7#, even if you were miserable. that 7# loss was from dehydration and malnutrition - NOT from the FAT loss that is what we're after.

The expected  weight loss (safe loss) is 1-2 # a week. In exceptional cases where someone is quite heavy and having NO trouble, more loss is OK - but NOT for most of us. This sounds like a bypass doc who does not know the specialized BAND things. He must be expecting a bypass-like loss.

Reflux does not mean the esophagus is dilated! It simply means, most of the time, that the fill is too much for that stage of banding.

We have to know the signs and symptoms of too much fill. if we experience them, and get back for an unfill within a day or two, there will usually be little damage that has occurred to the stoma and esophagus, and we can find relief with a small unfill. SMALL means 0.2 cc or so, maybe up to 0.4. If we wait longer, there is more swelling and damage, and we may need the entire fill out, plus even more, to allow rest and healing.


Pat, You'll certainly be able to get more fills in time. As we lose and the fat around the stomach and in the abdomen decreases, the band will loosen and we'll need periodic fill tweaks. also, with each fill, we need to refine and improve our band choices and lifestyle. There will be less and less room for error, the tighter we are. As you get better and better in your choices and food "processing" (chewing!) you'll be able to tolerate more fill in time.

Hope this helps -

Sandy r

Thanks for this post.  I have had some heartburn/reflux for the past couple months and wasn't sure what brought it on.  I am almost 2 years out from surgery and while I had bad heartburn/reflux before surgery, it pretty much went away after my surgery until it returned a couple months ago.  Even so, it's not near as bad as it used to be.  I haven't had a fill in probably 1-1/2 years, I'm guessing, so I doubt that it's related to that.  I actually notice it more when I'm hungry or on an empty stomach than I do after I eat.  Why is that?  I have been taking TUMS, which helps somewhat.  I sent an e-mail to the bariatric nurse, so I'll see what she says.  I did follow your suggestions last night with the food & drinks after dinner and didn't really have too many problems last night or this morning.  I notice it more when I have a little burp or something.