From the Guidelines
Chronic diarrhea after hiatus hernia repair is most likely caused by small intestinal bacterial overgrowth (SIBO) due to altered anatomy and motility changes, as well as potential vagal nerve injury during surgery, which can disrupt normal gut motility and lead to rapid intestinal transit time. According to the guidelines for the investigation of chronic diarrhoea in adults by the British Society of Gastroenterology 1, a detailed history is essential in assessing patients with chronic diarrhoea, including previous surgery, which can lead to diarrhoea due to lack of absorptive surface, decreased transit time, or changes in the bile acid pool.
Some key points to consider in the assessment of chronic diarrhoea after hiatus hernia repair include:
- Previous surgery, such as extensive resections of the ileum and right colon, which can lead to diarrhoea due to lack of absorptive surface and hence fat and carbohydrate malabsorption 1
- Bacterial overgrowth, which can often be a problem in situations where there are changes in anatomy, such as in bypass operations or gastric surgery 1
- Medication changes following surgery, which can sometimes cause diarrhoea as a side effect 1
- Potential unmasking of pre-existing conditions, such as irritable bowel syndrome or microscopic colitis
Management of chronic diarrhoea after hiatus hernia repair typically begins with dietary modifications, followed by medications like loperamide or cholestyramine if bile acid malabsorption is suspected 1. Patients should be evaluated with stool studies to rule out infectious causes and may require endoscopic evaluation if symptoms persist beyond 4-6 weeks post-surgery.
From the Research
Possible Reasons for Chronic Diarrhea after Hiatus Hernia Repair
- Delayed gastric emptying (DGE) following hiatus hernia surgery may be a contributing factor to chronic diarrhea, as it can lead to impaired quality of life, gastrointestinal symptomatology, and daily function 2.
- The development of chronic diarrhea after hiatus hernia repair may be related to changes in gastrointestinal motility, secretion, or absorption, which can be influenced by various pharmacologic agents used to treat chronic diarrhea 3.
- Recurrence of the hiatus hernia or other complications after surgery, such as pseudoachalasia or slipped/migrated wrap, may also contribute to the development of chronic diarrhea 4, 5.
- Temporal patterns of hiatus hernia recurrence and hiatal failure may play a role in the development of chronic diarrhea, with different types of recurrences and crural defects occurring at different times after primary surgery 5.
Factors Influencing Quality of Life after Hiatus Hernia Repair
- Quality of life after giant hiatus hernia repair can be improved with surgical repair, regardless of patient age, surgical technique, or the use of mesh 6.
- However, recurrence of the hiatus hernia after surgery may adversely impact quality of life, highlighting the importance of accurate diagnosis and optimal treatment 6, 5.
- Revision surgery for hiatus hernia recurrence can achieve adequate long-term satisfaction and quality of life, despite higher intraoperative morbidity 5.