NSAIDs After Bariatric Surgery 2

Can Patients Keep Taking NSAIDs After Bariatric Surgery?

June 11, 2018

Pain is a very common symptom in the general and bariatric population. The causes of pain are predominantly musculoskeletal in nature. This may be due to traumatic injuries, arthritis, spinal column abnormalities such as slipped disks, post-surgical issues such as replaced hips/knees, etc. Even though many of these ailments are treated in a multimodal fashion, the pillar of providing relief is by prescribing oral analgesics.

A class of drugs known as NSAIDs (Non-Steroidal Anti-Inflammatory) have revolutionized the way we manage and treat pain. NSAIDs proved analgesic, antipyretic and anti-inflammatory relief.

NSAIDs provide a very unique, multipronged, and systematic relief for a wide variety of ailments and symptoms. There are more than 20 different NSAIDs available commercially, most are used in combination with other drugs to provide optimal symptom relief. Some formulations such as Ibuprofen, Diclofenac, Ketoprofen, and Indomethacin are short-acting, less than six hours. Whereas others such as Naproxen, Celecoxib, Meloxicam, Nabumetone, and Piroxicam are longer acting, more than six hours. NSAIDs don’t change the nature of the disease process they only provide symptomatic relief.

How Do NSAIDs Work?

Most NSAIDs target an enzyme called Cyclooxygenase (COX which is a prostaglandin synthase).

This enzyme converts chemicals, in their active form, are responsible for inducing inflammation, fever, and pain. This commonly occurs after surgical procedures, trauma, and infections. Therefore, by blocking this active enzyme, all three processes are targeted with one drug.

One form of COX enzyme is predominantly present in the stomach, and it plays a crucial and beneficial role in maintaining the integrity of the stomach mucosal lining. This is essential in preventing infections and ulcers of the stomach. Many NSAID agents are non-specific; thus, inhibiting all COX enzymes. If used for prolonged periods of time, it will lead to stomach lining ulceration and potential infection with H. pylori bacterium, due to lack of mucosal integrity and protection. Eventually, this may even lead to stricture, bleeding, and occasionally life-threatening perforation of the stomach or the intestine.

As much as NSAIDs have revolutionized the way we manage inflammation, pain, and fever, their long-term use has lead to a myriad of gastric and intestinal pathologies. The kidney may also be affected negatively by NSAIDs, and careful evaluation and follow-up are needed to ensure damage is not inflicted on them using NSAIDs.

Effects of NSAIDs on post-Roux-en-Y Gastric Bypass Patients

The upper part of the digestive tract is changed after Roux-en-Y Gastric Bypass. The new anatomy consists of a small stomach pouch, which is connected to the small intestine, the gastric remnant is then drained into the distal small intestine which allows the gastric juices and bile to mix with ingested food.

NSAIDs can cause ‘marginal’ and ‘gastric remnant’ ulcers in patients who have undergone RNY Gastric Bypass. Marginal ulcers occur at the junction between the gastric pouch and the small intestine; this connection (anastomosis) is vulnerable when NSAIDs are consumed. This leads to denuding of the protective mucosal layer and thus ulceration and its sequelae.

Our bodies are exceptionally efficient at healing after an insult, especially our digestive organs. However, prolonged usage of NSAIDs will not allow the organs sufficient time to heal. They are eventually overcoming the body’s ability to neutralize the toxic and adverse effects of these medications, resulting in non-healing chronic ulcers. These ulcers will progress, causing pain, narrowing of the gastrojejunal anastomosis, bleeding, and eventually life-threatening perforation requiring emergency surgical intervention.

Short-term usage of NSAIDs is tolerated in most patients when it’s done under medical supervision, with gastro-protective regimens such as PPIs (proton pump inhibitors).

Therefore, it’s imperative to seek immediate medical attention if you start experiencing increasing epigastric pain, new or worsening heartburn symptoms, change in stool color to that of a dark coffee ground, persistent nausea, vomiting, inability to tolerate diet, or sudden onset severe abdominal pain as this may be a sign of perforation.

Treatment of NSAID Side Effects and Complications

The sooner the problem is accurately diagnosed, the more successful the treatment plans.

Generally, treatment starts by stopping the offending agent, which in most cases is an NSAID. However, other medications and social habits such as smoking, consuming caffeinated or alcoholic drinks also play a role in exacerbating the condition.

A thorough workup is necessary to make a correct diagnosis. Upper gastrointestinal imaging, which includes barium/gastrografin series, CT of the chest/abdomen and pelvis scan with oral and intravenous contrast along with endoscopy (EGD, esophagogastroduodenoscopy) is necessary for evaluating and diagnosing the etiology of the condition. The treatment is then tailored to reverse the problem. If the findings are of early ulceration at the gastrojejunal anastomosis, then a course of PPIs (i.e., omeprazole, pantoprazole, Lansoprazole, Dexlansoprazole, etc.) with Sucralfate (Carafate, Orafate) is given for about 6-8 weeks, and repeat studies are performed to ensure resolution of the ulcer.

If the ulceration is long-standing and has progressed to narrowing the gastrojejunal anastomosis, then mechanical dilation is required. Occasionally, multiple dilations are required along with the PPIs and sucralfate to avoid surgical intervention.

However, in certain situations, if all of the above fails, surgical revision of the gastrojejunal anastomosis is necessary. Of course, this should only be attempted by an experienced surgeon.

NSAIDs After Bariatric Surgery Summary

In summary, NSAIDs are best-avoided post-RNY Gastric Bypass surgery. If your physician thinks it’s necessary for you to have a short course of NSAIDs, I recommend discussing that with your bariatric surgeon to minimize the undesired side effects of the drug.

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Dr. Husain Abbas of Memorial Advanced Surgery, is a Board Certified surgeon trained in Minimally Invasive Surgery. After his surgical residency at St. Mary's, a Yale University affiliated hospital, Dr. Abbas completed a fellowship in Minimally Invasive Gastroesophageal & Bariatric Surgery at the University of Florida, Gainesville. Dr. Abbas' expertise extends to a wide array of gastroesophageal disorders, anti-reflux surgery, complex hernia repairs, endocrine, oncology and bariatric procedures.

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