Gastro-Gastric Fistula
on 3/28/15 10:43 am
You need to find a surgeon who deals with revisions. I don't think you surgeon is experienced enough with the issue. That's not a knock on him but you need a revision surgeon. My surgeon did my EGD so he could see for himself what he was dealing with.
"The first thing I do in the morning is brush my teeth and sharpen my tongue." --- Dorothy Parker
"You may not like what I say or how I say it, but it may be just exactly what you need to hear." ---Kathryn White
on 3/26/15 2:24 pm
I had a Gastrogastric fistula. I will answer any questions I can for you.
"The first thing I do in the morning is brush my teeth and sharpen my tongue." --- Dorothy Parker
"You may not like what I say or how I say it, but it may be just exactly what you need to hear." ---Kathryn White
After extensive testing I was told that they couldn't do a simple repair so I opted to have a revision done. They had to go in surgically to repair the fistula so decided to go ahead and have a revision done to the DS. That was 2 years ago. I have since lost 140lbs and feel great. A lot of my food allergies have subsided, my gastric reflux is gone and I have energy that I haven't had in along time. I don't suffer from the pain that comes from being morbidly obese. I have a wonderful surgeon and I believe that is key to these surgeries. You must have someone who knows what they are doing and are experienced. Good luck with whatever you decide.
If you don't mind me asking how did you first realize you had a fistula? Did you have any pain? I have a pinching type of pain especially when I eat. My dr said its probably reflux. I do have Gerd and have had reflux for years though and never this type of pain. He increased my omeprazole. But still have pain.
on 3/28/15 6:19 am
Unfortunately some can't be revised to a DS. You were fortunate. I personally was fine with maintaining my pouch, however I was revised to a Distal bypass, which I love.
A gastrogastric fistula is when the blind stomach reattaches to the pouch and forms a hole. I had bile backing up and I was inhaling it. Extreme pain and vomiting of bile.
Did you have a bypass? Are you on a PPI?
"The first thing I do in the morning is brush my teeth and sharpen my tongue." --- Dorothy Parker
"You may not like what I say or how I say it, but it may be just exactly what you need to hear." ---Kathryn White
I had some pain but not a lot. My biggest issue was gaining my weight back. I did have a lot of coughing- it felt like I always had a flutter in my chest when I would inhale. I had some reflux and I also developed a lot of food sensitivities and malapsorption of certain vitamins and minerals. Try to get them to do an upper GI and trace where the liquid goes. That will show if it is going where it needs to be. Good luck. I know your frustration and it can be a very difficult journey to be on. A fistula is fairly rare. My Dr said only 1% of those having Gastric bypass end up with a fistula but it does happen.
Sharon
Question
QUESTION: I am a 58 year old female who had RNY Gastric bypass in 2003. I lost 145 pounds, but regained about 50. I have had complications with perforated ulcers (twice) and bleeding ulcers (once). A gastrogastric fistula from the first ulcer was found to be the causative culprit and was finally repaired (along with a vagotomy)in Aug. 2007. In April 2008, the coughing began. It escalated through the summer and I was seen by pulmonologist, allergists, and gastroenterologist. I had chest Xrays, sinus X-rays, upper GI, and multiple allergy tests all to no avail. The specialist threw their hands up in despair as I was coughing 24/7 (even unable to hold conversation with my doctors!) and then I went to a bariatric surgeon (my own had retired) because I had an incarcerated hernia (I had managed to reduce it on my own, but saw him one week later.) He felt that it was reasonable to believe the hernia was causing reflux and therefore the cough. (although I had had testing for reflux). The surgery was done, the coughing improved (did not disappear), but within a month or so was back. It escalated through Jan. and I finally went to my PC who diagnosed pneumonia. I have completed 10 days of Avelox, but the cough persists. I had a chest Xray two days ago; it was normal. I do have a bulge that MAY (according to my PC) be another hernia but it has not broken through the wall. My question is this: as a post bariatric surgical patient, it is possible that reflux through my pouch is the causative factor and if so, what kind of testing should be done to determine that? I am so very tired of coughing. Please help!
ANSWER: Wow Pat, this is a really tough problem.
First, let me say that it DOES seem quite possible that the source of your coughing and pneumonia is reflux and aspiration of small amounts of fluid from your stomach. I say this in the assumption that the other doctors (especially the pulmonologist) have made a good try at diagnosing a problem coming directly from your respiratory system. My remaining comments have to do with:
-how can reflux aspiration be confirmed
-where might it come from
-how to treat it
You wrote that you had testing for reflux, and I perceive this was negative/normal. The thing is that even tiny amounts of harsh/irritating digestive juice can cause problems if it gets into your sensitive lungs. Rather than have you tell me about all the tests that have been done, I suggest for you to go back to the gastro-enterologist and ask him/her to help look for ANY acid or bile reflux. You may also benefit from having an ENT doctor do a scope to look at your larynx and vocal cords - if these are inflamed it is a pretty sure bet that aspiration is the cause.
You can have lung-damaging reflux that is composed of acid, or of digestive juice that comes from deeper down in your digestive tract - bile and pancreatic juice. These juices are normally present, and the medical problem is that they are (maybe) washing backwards up your esophagus instead of traveling downstream. The first abnormality is probably that you have a weak valve at the top of your stomach (called the Lower Esophageal Sphincter), and this is probably further weakened by a Hiatal Hernia. (I have in mind that you will Google some of these terms for further info if you need to.) The GI doctor can help determine if these problems are present. The second abnormality that MAY be present is a recurrent fistula. This may be a surprise to you, but there is a fairly high rate of fistula recurrence and if one is present that would be a "shortcut" for digestive juices from your bypassed stomach to your espophagus. This possibility can be tested by CT scan or Upper GI X-ray, with CT being more helpful in most cases. The third abnormality that may be present (and probably is present) is slow motility of your Roux limb and small intestine. Based on your earlier experience with the hernia, it sounds to me like there is a good chance of some kink or twist of your intestine that is making it hard for fluids to pass downstream as they should - fluids back up and end up in your esophagus. This kinking or twisting (technically called a partial small bowel obstruction) may be caused by a recurrent hernia or may be related to scar tissue deeper inside your abdomen. CT scan is useful to fill in this information as well.
Treatment is guided by the findings of tests, but here are some possibilities:
-acid blocking medicine such as Nexium (my bet is that you are already on this)
-medicine to help your intestine move better, called Reglan (pretty good chance you are already on this, and it would only help if there is NOT a partial bowel obstruction)
-Questran, which is a powder that soaks up excess bile. It might be useful to take this just before bed since most people aspirate while laying down at night
-sleep in a tilted position with the head higher than feet (called reverse Trendelenburg position, this is different than propping up your head on pillows). This should get gravity to help keep the stuff down where it belongs
-Don't eat or drink within 2 hours of bed. No chocolate, tobacco, alcohol.
Surgical possibilities - only to be chosen if an experienced surgeon believes they may be helpful:
-Hiatal Hernia repair
-abdominal exploration for PSBO
-repair of ventral hernia
-move the jejuno-jejunal anastomosis downstream, so that digestive juices have a harder time getting back to the esophagus
-fistula repair, if recurrent fistula
As I look back at this reply, I find that it has necessarily become rather technical. You may wish to take this to your primary MD to see if this gives him/her any additional ideas on how to help get your lungs in better shape.
Best wishes,
Dr JP
