Coughing at Night

This week I saw two patients in the office who complained of reflux and coughing when they laid down at night. Both had had an adjustable gastric band placed a few years ago and had not had a recent adjustment to there band.

Their symptoms are related to the band being too tight causing back up of saliva in their esophagus. When they lay down the pooling of saliva can overcome the ability of the muscle at the upper end of the esophagus to keep the saliva out of the throat.

When the contents of the esophagus come up into the throat it they can come in contact with the vocal cords and cause coughing. Occasionally this will aspiration of these contents into the lungs and cause pneumonia.

This problem is usually rectified by taking some fluid out of the band.
In both cases this immediately relieved the symptoms in both of these individuals and they were able to drink water comfortably.

Although this solved the immediate problem, band slippage could be the reason this has only recently developed.

If the problem recur rs with or without placing more fluid into the band the patient should be investigated with a special X-ray such as an upper GI or a CT scan to determine whether slippage has occurred.

If the band has been forced to slip down further on the stomach the band may have to be repositioned with another laparoscopic operation. Hopefully this will not be the case for either of these individuals and they will be able to avoid another operation. I will be seeing each of them in the office again in a few weeks for follow up.

Managing Nausea and Vomiting after Bariatric Surgery

Two nights ago I met one of our patients in the emergency room because she was unable to control the sensation of nausea and had been vomiting at home. I had just discharged her from the hospital that very morning after an uneventful time in the hospital following a laparoscopic gastric bypass two days before. Most patients do not complain of these symptoms after bariatric surgery but occasionally nausea is significant problem.

Here are three steps to avoiding nausea and vomiting after bariatric surgery:

1). Maximizing prevention by medications given prior to surgery. My routine for my patients includes Zofran 4 mg given intravenously by the nurse just before surgery. I also order Decadron 10 mg through IV just before surgery as long as the patient is not diabetic. (This steroid medication will cause a high sugar level in diabetic patient.) Finally, if the patient has had nausea with previous operations or has a history of motion sickness I will prescribe a scopolamine patch to be placed behind the ear starting the night before surgery. This helps to prevent motion sickness but can be very helpful to prevent nausea after an operation as well. This patch can stay on for three days delivering a small amount of medicine slowly during this time. The reason it should go on the night before is to assure an appropriate amount has been absorbed by the time surgery starts.

2). After surgery my preferred medication is Zofran if the patient feels nauseated. This can be given through the IV while in the hospital or by mouth in pill form if the patient is at home. The scopolamine patch can be added for more severe symptoms. I prefer to avoid medications such as Phenergan or Compazine since they can cause very bothersome side effects.

3). Finally the speed of taking fluids may need to change. If you feel nauseated I suggest you slow down even more taking only teaspoons of fluid at a time and waiting at least 30 seconds between swallows since it takes about that long for the swallow to reach your revised stomach. Sometimes it is helpful to take the fluids at room temperature as well.

If the nausea and vomiting persists call your surgeon so you don't become dehydrated.

If nausea and vomiting develops weeks, months or years after bariatric surgery consult your doctor or surgeon as this may be a symptom of a narrowing or ulcer.

With good preoperatve preparation nausea and vomiting can usually be avoided.. However, if it does occur I hope this posting is helpful to you..