Barium Swallow Fluoroscope for Protein Problems

[Clematis]

I had a barium swallow fluoroscope test today because I haven’t been able to eat dense protein without discomfort and vomiting since my surgery 7.5 months ago.

To recap:

Sep 2015
I was DXed with “silent” reflux and placed on 40 my omeprazole. Within a week I puked up the meat from my dinner 14 hours earlier as if I had just eaten it. Plus I was awaking at 2 am gasping for air with my dinner in my throat. Despite sleeping on a bed wedge and tremendous weight loss, I still have this middle of the night reflux if I eat after 8pm — even vitamins if I take them after 8. It feels like stomach contents come up under force, which they would have to to come uphill in the esophagus while on the bed wedge.

Nov 2015
Had the DS. But since then, whenever I eat even small amounts of dense protein, it hangs up in my stomach, it aches, then I puke it up. Occasionally this also happens with bread, as if it makes a dough ball and hangs up. Of course ice cream and cookies slide right down.

My theories were not enough acid to digest protein so I reduced PPI from 40mg to 20mg and I do think it helped a small bit. My other theory was a stomach stricture.

Jun 2016
This morning I had a barium swallow fluoroscope test. I liked the radiologist a lot. He had never heard of the DS (they are just not performed around here much) — but he only had to think of it as a VSG as that’s where the problem lies. (I was unclear whether he’d ever scoped a VSG. When we parted he said it might take him a day to come up with a report that sounded somewhat intelligent so I'm guessing I was his first.)

He said he thinks my sleeve has a twist causing a stricture. I don;t think it's horrible, though. From what I saw, it looks like a pouch has formed above the stricture which sags off to the side. I wonder if this is where the protein gets road blocked and has caused stretching… before I puke it up. To me, the stricture has an opening the diameter of my pinky so nothing is going to get strangulated.

He said the stricture was in the part of my sleeve where the stomach had been excised, not in the normal lower part… huh? Doesn’t the VSG remove the outer part of the entire length of the stomach?

The last bit of fun was swallowing barium while lying flat on my stomach — not easy to do. It immediately flowed back into my esophagus so, yeah, I definitely have reflux.

All this is beyond the scope of my PCP so I guess I have to find a gastroenterologist.

I don;t know what can be done about all this. I think they can stretch a stricture with a balloon but I don;t know how that works when the sleeve is twisted. Do they have to surgically straighten it?

As for the reflux, there is clearly a problem with my lower esophageal sphincter. It is truly frightening waking in the middle of the night unable to get in air because my dinner is in my throat. Weird that I had mild symptomless reflux before starting a PPI and then almost immediately developed regurgitation of undigested protein during sleep. So I do believe the PPI has left me with too little acid to digest protein which in turn slows gastric emptying so when reflux happens while sleeping, actual solids are in my throat, not just a spray of stomach acid. Urecholene can strengthen the esophageal sphincter, lower acid and improve movement of food through stomach so maybe that will be recommended.

Any other thoughts?

 

[DSRIGGS]

That pouch you describe sounds like a hiatal hernia to me. As far as the twisting my GI thought I had a twisted stomach but then when I showed the pictures to Dr Marshall my original DS surgeon and Dr K they both said it wasnt twisted. That certainly doesn't mean you don have a twist....that was just my experience.

Regarding your pyloric valbe and potential gastroparesis (that is what would happen if it isn't releasing food) the way to effectively study that is a 4 hour gastric emptying study. That is how we finally learned of Cameron's issues. The standard one hour emptying study showed Cameron emptying fine because he started off emptying okay and then it stopped so it gave a false negative result.

Good on you for finally getting this upper gi study. You have lived with this long enough. Hopefully they can get a good solid diagnosis and a reasobaby easy fix for you. It is time for you to be able to eat without all these problems.

Best of luck to you and my positive mojo coming your way for a quick and complete fix.

 

[duh_Mom]

@Clematis sure sounds surgical to me. I would be very hesitate to let them ballon a stricture in a stomach that has been surgically reduced. Scar tissue does not stretch.
I am so sorry you are going through this - but I am glad they have finally figured out what is going on.

 

[DSRIGGS]

There is a procedure to help with pyloric function as well but that is obviously cart before the horse. Hopefully you can get the written study tomorrow and can get a few opinions from Docs and I would suggest consulting with Dr K. He figure it out for Cameron. He would at least have ideas for you to contemplate and if a procedure was needed I bet somebody at the Cleveland Clinic would be able to do it.

Best wishes.

 

[Clematis]

Oh yeah I forgot: he said I have a small hiatal hernia but he couldn't tell if it was sliding or fixed.

@duh_Mom What you say makes perfect sense to me but I know I've read of VSG/DS patients here or FB or OH who have had balloon stretching. Do you think it could be fixed with endoscopic surgery? They need to fix this outpatient -- insurance will not pay for inpatient procedures regarding the unapproved WLS surgery.

@DSRIGGS I think my pylorus is ok. It's the lower esophageal sphincter that is misbehaving. And then there's that stricture/twist. BTW, he didn't even notice the stricture/twist until he had me change positions.

I need to find a gastric surgeon with extensive experience with VSG. The radiology report should be faxed to my PCP tomorrow -- she is so un-computer savvy that she can't even figure out how to access the report online.

 

[DSRIGGS]

Oh yeah I forgot: he said I have a small hiatal hernia but he couldn't tell if it was sliding or fixed.

@duh_Mom What you say makes perfect sense to me but I know I've read of VSG/DS patients here or FB or OH who have had balloon stretching. Do you think it could be fixed with endoscopic surgery? They need to fix this outpatient -- insurance will not pay for inpatient procedures regarding the unapproved WLS surgery.

@DSRIGGS I think my pylorus is ok. It's the lower esophageal sphincter that is misbehaving. And then there's that stricture/twist. BTW, he didn't even notice the stricture/twist until he had me change positions.

I need to find a gastric surgeon with extensive experience with VSG. The radiology report should be faxed to my PCP tomorrow -- she is so un-computer savvy that she can't even figure out how to access the report online.

I missed the esophageal part. My bad.

 

[Spiky Bugger]

I'm just hurting for you.

 

[Clematis]

I'm just hurting for you.

I'm FINE, really. Just can't eat dense protein without vomiting. Millions of people thrive never eating dense protein. I'm sure you'd trade this for your wretched kidney stones any day.

@DSRIGGS I woke at 4 this morning wondering if I don;t have a sleeve problem per se, rather just a sliding hiatal hernia that is pinching up the top part of the sleeve and causing a stricture. This would align with my earlier post-op feelings of food not actually making it in my stomach, as well as explain how once in a blue moon I can eat a couple ounces of meat but then puke up the identical type and amount of meat the next day.

 

[Larra]

Remember that no diagnostic test is perfect. What is being called twisting may in reality be a stricture. The treatment for each of these problems may be quite different. I don't know if the stricture, if that's what it is, can be dilated endoscopicly - it might depend on location, how tight it is, etc. And a twist, if that really is the problem, would need surgery to fix.
Rather than all of us speculating further, it seems to me that the next step (assuming you want to take further steps) would be upper endoscopy to actually see the problem from the inside of the sleeve.
And if it is something that could be dilated endoscopicly, hopefully that could be done as an outpatient procedure.

 

[Clematis]

I need to schedule an endoscopy.

Here's the full report if you're looking for something to do to fill the next five minutes (yawn):

CLINICAL HISTORY
History of vertical sleeve partial gastrectomy with duodenal switch procedure. History of reflux. Complaining of inability to digest protein food. Regurgitation os any digested proteinaceous food.

FINDINGS
Routine single contrast barium swallow and double contrast upper GI series performed. Total fluoroscopy time was 5.2 minutes. Total ingested barium was 330 mL.

The oral phase of swallowing was well coordinated and strong. There was mild but insignificant mass effect upon the posterior cervical esophagus caused by osteophytes at C5-6 and C6-7. There was no aspiration, penetration of the airway, or nasopharyngeal reflux.

There was a small fixed hiatal hernia. There were transient spasms in the distal esophagus. There was reflux into the esophagus during the exam. There was mild narrowing of the junction of the hiatal hernia with the remainder of the stomach at the level of the diaphragm. There was no constricting esophageal lesion or gross esophageal ulceration in this exam.

The patient has had previous vertical sleeve partial gastrectomy. Gastric sleeve shows relatively static appearance once filled, with narrowing, resulting in a mild degree of delay in emptying of the gastric sleeve. The mucosal fold pattern at the anastomosis however is unremarkable, and the proximal limb just distal to the gastroenterostomy was otherwise unremarkable.

Opacified loops of distal small bowel were unremarkable.

IMPRESSION
Previous history of vertical sleeve partial gastrectomy with duodenal switch procedure.

There is a small fixed hiatal hernia, and there was mild gastroesophageal reflux during this exam. There was narrowing at the bottom of the hernia as it passed through the esophagus which could simply be because of the hiatus, but could also represent a stricture. In addition, there is narrowing at the gastroenterostomy site. Recommend direct visualization with upper endoscopy.

Transient spasms in the distal esophagus.

 

[Larra]

Well!
The radiologist, had he been so inclined, could have actually looked up DS. Had he done so, he would have realized that you don't have a gastroenterotomy at all, let alone a narrowed gastroenterotomy.
Also, in his impressions, he says that "there was narrowing at the bottom of the hernia as it passed through the esophagus". Again, well! The esophagus passed through the hernia, NOT the hernia through the esophagus!
And it would be helpful if he specified where the narrowing of your static looking sleeve is.

I'm guessing that there really is a stricture somewhere, and this guy just doesn't know how to assess a gastric sleeve very well. Better get that endoscopy scheduled, and take a diagram of the DS with you just in case the GI doc knows as little as the radiologist.

 

[Clematis]

Love ya Larra. Thanks. Haha yeah I wondered about the gastroenterotomy part as I didn't think I had one. (I then got a little nervous that my surgeon had done a cubist Picasso version of the DS and God knows what WLS I had.) I forgot to show him the diagram even though I have it on my phone, but I did tell him several times that I did NOT have roux en-y gastric bypass, I had a fully functioning stomach with pylorus, not a pouch. I can understand him being clueless about the DS as, inexplicably, very few are done in Cleveland. I told him that and he volunteered that loads of VSGs are done. Since he was in his 40s and had been there for more than a decade, I just assumed he had personal experience with visualizing a VSG but I guess not.

 

[aaa]

Does the Cleveland Clinic have any gastric surgeons you know of? That hospital has a very good reputation.

 

[Clematis]

The Cleveland Clinic has a very good brand. The Clinic does not do DS. Well, they don't advertise that they perform DS but they do about a handful a year on SMO. They have the antiquated mind set that the DS is too risky -- they also give abysmal nutrition advice so in a way it is risky for the patients who follow their advice. (But they do still put in lap bands. Geez.) Not a good enough record for me, hence my having surgery out of town. We also have University Hospitals (who just started advertising that they do DS in the past few months) as well as a catholic hospital that started doing WLS nearly 30 years ago, long before the other two hospital systems (they do not do DS). We are awash in doctors in this town so I am sure to find several if not many gastros with some knowledge of a VSG. My PCP is loosely associated with UH but recommended an independent gastroenterology center (i.e. colonoscopy factory). I'm going to call the UH bariatric center on Tuesday and ask them for a referral to a UH gastro with extensive knowledge of VSG.

 

[DSRIGGS]

Sounds like you are on your way to some answers and I am happy for you.

It is amazing at how ignorant many in the medical field are outside of their area of specialization. One would have thought a radiologist would have seen a little bit of everything but apparently this one has not. In any case, the important thing is that you got the testing and as Larra said and upper endoscope should show what needs to be seen so hopefully a fix can be put in place quickly. Time for you to be able to eat some damn meat!