What is the management approach for chronic nausea and vomiting post bariatric surgery?

Management of Chronic Nausea and Vomiting Post Bariatric Surgery

The management of chronic nausea and vomiting after bariatric surgery requires a systematic approach addressing both potential surgical complications and behavioral factors, with immediate focus on ruling out mechanical obstruction and maintaining adequate hydration.

Initial Assessment

• Evaluate for alarming signs such as tachycardia ≥110 beats per minute, fever ≥38°C, hypotension, respiratory distress, or decreased urine output, which may indicate serious complications like anastomotic leak or staple line leak 1
• Persistent vomiting despite compliance with nutritional recommendations may indicate surgical complications including band slippage, esophageal stricture, bowel obstruction, reflux, or gastric ulcers 1
• Assess for signs of dehydration, as one-third of all postoperative bariatric emergency room visits within 3 months after surgery are related to dehydration 1
• Rule out mechanical obstruction with upper endoscopy as the first step in the diagnostic algorithm, especially before diagnosing a functional or motility disorder 2

Diagnostic Workup

• Perform gastric emptying scintigraphy for at least 2 hours (preferably 4 hours) to evaluate for gastroparesis, which may develop after bariatric surgery 2
• Consider breath testing as an alternative if scintigraphy is unavailable 2
• Evaluate for internal hernia, particularly in patients with acute onset, persistent crampy/colicky abdominal pain located in the epigastrium after Roux-en-Y gastric bypass 1
• Check thiamin levels when vomiting persists for >2-3 weeks to prevent neurological side effects 1, 2
• Assess eating behaviors, as inappropriate eating behaviors are related to vomiting in 30-60% of patients after bariatric surgeries 1

Management Strategies

Nutritional Interventions

• Focus on slowing the pace of eating, prolonged chewing (≥15 "chews" per bite), and avoiding dry foods such as doughy bread, overcooked steak, and dry chicken breast 1
• Recommend small, frequent meals with lower fat and fiber content 2
• Ensure adequate hydration with consumption of 1.5 L liquids/day 1
• Separate liquids from solid foods to improve tolerance 1
• For food-specific vomiting, recommend reintroducing problematic foods later when the patient has acquired new nutritional skills 1

Pharmacological Management

• Implement a multimodal approach for prevention of nausea and vomiting, including:

  • 5-hydroxytryptamine receptor antagonists (e.g., ondansetron) 1
  • Long-acting corticosteroids like dexamethasone 1
  • Neurokinin-1 receptor antagonists (e.g., aprepitant) 3, 4
  • Butyrophenones, antihistamines, or anticholinergics as needed 1

• Consider aprepitant as an addition to standard antiemetic therapy, as it has been shown to significantly delay vomiting episodes and lower the incidence of postoperative vomiting in bariatric patients 4

• For patients with laparoscopic adjustable gastric band (LAGB) experiencing persistent vomiting, band opening may be helpful 1

Anesthetic Considerations for Future Procedures

• If the patient requires future surgeries, consider total intravenous anesthesia with propofol (TIVA) and avoidance of volatile anesthetics and opioids to reduce risk of PONV 1
• Consider sugammadex over neostigmine for neuromuscular blockade reversal in future surgeries, as it has been associated with reduced incidence and severity of PONV 5

Special Considerations

• Female patients have higher risk of PONV after bariatric surgery and may require more aggressive management 6
• Sleeve gastrectomy patients experience higher rates of PONV compared to Roux-en-Y gastric bypass patients and may need more intensive treatment 6
• For patients with persistent symptoms despite normal gastric emptying, consider antroduodenal manometry to evaluate for other motility disorders 2

Complications to Monitor

• Monitor for dehydration, which can occur when patients find it difficult to maintain adequate fluid intake 1
• Watch for thiamin deficiency in cases of prolonged vomiting, which can lead to neurological complications 1
• Assess for nutritional deficiencies resulting from persistent food intolerance, which may lead to food avoidance and maladaptive eating behaviors 1

Follow-up Recommendations

• Schedule regular follow-ups to monitor response to interventions and adjust treatment as needed
• Evaluate for improvement in symptoms and nutritional status
• Consider surgical intervention if symptoms persist despite medical management and are due to anatomical complications 1