Diarrhea after Bariatric Surgery

Let’s phase it, firstly no one likes to talk about this embarrassing topic diarrhea after Bariatric Surgery.

But, if anyone struggling with this symptoms after bariatric surgery however NEEDS solutions!

Now, Roux-en-Y gastric bypass has a known side effect of dumping syndrome, i.e. which can cause diarrhea.  So, We are excluding it from this discussion.  I want to go outside the obviously.

So, let’s dig into the seven causes of diarrhea after bariatric surgery. 

What is diarrhea ?

Especially, I like to use the Bristol stool chart as my guide.  It helps you be more specifically with what’s happening. 

For example, chronic loose stools is evidence something is off and qualify in the diarrhea category. 

When you utilize the Bristol stool chart, number four is considered the “perfect poop”, with number three being a close second.  Then number five is considered a loose stool, with watery diarrhea being number seven. 

So for the sake of this discussion, we are discussing “diarrhea” stools between five and seven on the Bristol stool chart. 

Pre-surgery diarrhea

Bariatric surgery alters digestion, therefore increasing the risks of embarrassing symptoms like diarrhea.  But what about prior to bariatric surgery?

A study published in 2014 found around 8% of bariatric patients prior to surgery experience diarrhea, moreover, its being twice as high as seen in lean people.  Although Roux-en-Y gastric bypass and duodenal switch patients will likely experience more diarrhea, not including sleeve gastrectomy would inaccurate.  As a matter of fact, diarrhea is a risk factor after sleeve gastrectomy too.

7 causes of diarrhea after bariatric surgery

A study published in 2014 reports up to 75% of patients suffer from alterations in bowel habits and fecal transit time after roux-y-gastric bypass. Similarly with diarrhea being the most common & usual symptom after gastric bypass and duodenal switch. 

So seven non-dumping causes of diarrhea consist of…

1. Malabsorption of carbohydrates
2. Small intestinal bacterial overgrowth(SIBO)
3. Clostridium Difficile( C-Diff)
4. Bile acid malabsorption
5. Exocrine pancreatic insufficiency
6. Dysbiosis
7. Cholecystectomy(gallbladder removal)

Diarrhea after bariatric surgery due to malabsorption of carbohydrates

Meanwhile certain carbohydrates are associated with poor absorption for some people.  Then, these include lactose, fructose, sucrose and FODMAPs. 

Although these intolerances are unlikely to be “urgent” in the sense that it will occur in fifteen to thirty minutes of consuming.  Diarrhea will likewise occur in correlation to digestion. Everyone is different of course, but typically this can be anywhere from two to eight hours after consuming.  

Since, the most common symptoms of carbohydrate malabsorption are…

1. Gas
2. Bloating
3. Diarrhea
4. Abdominal discomfort

So, one underlying cause that leads to carbohydrate malabsorption is small intestinal bacterial overgrowth(SIBO).

Small intestinal bacterial overgrowth(SIBO) and diarrhea

Moreover, one common cause of diarrhea is small intestinal bacterial overgrowth(SIBO).  A study published in 2017 reports 15% of pre-surgery obese patients are positive for SIBO.  So, this increases to 40% after bariatric surgery.  Additionally, studies go as high as 82% after bariatric surgery. 

There are three types of SIBO:

1. Hydrogen
2. Methane
3. Hydrogen sulfide

Hence, individuals with diarrhea dominated SIBO typically have an overgrowth of hydrogen or hydrogen sulfide gasses. Whereas those with methane dominant SIBO will likely experience constipation. 

A study published in 2020 compared Roux-en-Y gastric bypass, omega bypass and sleeve gastrectomy patients.  Since, they found the risk for SIBO was the same across all three surgeries.  Surprisingly, this same study found SIBO was more common in older females after PPI treatment. 

The most common symptoms of SIBO driven diarrhea are…

1. Abdominal pain
2. Nausea
3. Bloating
4. Gas 
5. Diarrhea
6. Malnutrition
7. Loss of appetite
8. Feeling of fullness after eating 

Now let’s discuss a cause of diarrhea that can be quite severe. 

Clostridium difficile(C-Diff) diarrhea

C-diff is a bacteria that causes diarrhea and inflames the colon.  Unfortunately, C-diff is highly contagious and needs to be treated with importance.  But what puts you at risk after bariatric surgery? 

A study published in 2019 reports the alteration of the gastrointestinal climate caused by obesity, antibiotic therapy or surgery is a risk factor for clostridium associated colitis.  Making c-diff a potential risk for any bariatric surgery. 

The most common signs of C-diff…

1. Watery diarrhea, as often as 10-15 times daily
2. Abdominal cramping and pain
3. Rapid heart rate
4. Dehydration
5. Fever
6. Nausea

C-diff can be quite debilitating, especially right after bariatric surgery making it quite concerning.

A study published in 2019 found that starting probiotics within 1-2 days of the first dose of antibiotics in hospital patients prevented c-diff infections.  Pretty impressive!   Now, let’s move on to a very common cause of diarrhea after bariatric surgery. 

Bile acid Diarrhea(BAD)

Bile acid diarrhea is a common cause of chronic diarrhea and is characterized by excess bile acids within the colon.  So, its resulting in increased colonic motility and secretion. 

Bile acid malabsorption can be why someone would experience diarrhea after bariatric surgery.  There are three types of BAD:

1. Structural-usually surgical
2. Idiopathic- Increased bile acid production
3. Secondary- GI conditions that result in the malabsorption of bile acids
   • Gallbladder removal
   • Celiac disease
   • Chronic pancreatitis
   • Microscopic colitis
   • SIBO

Typically, those experiencing BAD will have similar symptoms.  This includes..

1. Frequent stools
2. Urgent stools
3. Nocturnal defecation
4. Excessive gas
5. Abdominal pain
6. Stool incontinence

Exocrine pancreatic insufficiency(EPI) after bariatric surgery

Exocrine pancreatic insufficiency is an insufficient secretion of pancreatic enzymes and/or sodium bicarbonate.  It is a known complication after upper gastrointestinal surgeries. 

More and more studies are showing the prevalence of EPI after bariatric surgery.  Although having a gastrectomy can influence exocrine function, EPI is more common after roux-en-y gastric bypass.   In fact, one study published in 2019 found that sleeve gastrectomy actually relieves EPI. 

Symptoms of EPI…

1. Abdominal pain, gas and bloating
2. Diarrhea
3. Fatty stools(pale, oily, foul smelling poop that floats)
4. Unexplained weight loss

Dysbiosis

Dysbiosis is an imbalance in your gut bacteria.  This includes too little good bacteria, too much bad bacteria or too much bacteria in the wrong location. 

Too many of the bad bugs can be a result of an overgrowth of pathogens or parasites.  This can come from your food supply, environment or traveling. 

If you’ve ruled out several causes of diarrhea and haven’t dug into what’s happening in your gut, I would consider a stool test.  The GI Map stool test is a great option to detect the DNA of pathogens and parasites that may be present in low levels.  This is why maintaining a healthy gut microbiome is so important after bariatric surgery.  It’s about making you more resilient too pathogens. 

Gallbladder removal causing diarrhea 

Once you’ve had your gallbladder removed afterwards bile management changes.  This can lead to secondary bile acid malabsorption.

You see, your liver is where bile is produced, and your gallbladder is where it is stored.  Once the storage facility is removed there is a chronic drip of bile directly into the small intestines. Then the majority of bile doesn’t get reabsorbed and recirculated back to the liver, it passes into the colon.  This is where diarrhea occurs.

The most common symptoms experienced post gallbladder removal are…

1. Fatty food intolerance
2. Nausea
3. Vomiting
4. Heartburn
5. Gas
6. Indigestion
7. Diarrhea
8. Intermittent episodes of abdominal pain
9. Jaundice

Conclusion

As you can see diarrhea can have several causes. Once you understand if SIBO, C-Diff, BAD, dysbiosis or a carbohydrate intolerance is driving your diarrhea you can quickly apply solutions to prevent it from reoccurring. This is why Working with a provider like myself who can help you understand what’s at the root will likely improve your results much more quickly.