Diarrhea after bariatric surgery

Dawn: (00:00)
Hello, and welcome to the gastric health show. My name is Dawn Boxell and we are here this week and we are going to discuss the seven causes of diarrhea after bariatric surgery. Now, I know no one likes to discuss this embarrassing topic. But if you have this issue, you need solutions. So this is why we’re going to discuss it because unfortunately I do see a lot of this within the bariatric population. And there are some very common reasons why, or some very common drivers that would give someone diarrhea

Dawn: (00:48)
Now with the Roux-en-Y gastric bypass, we, it is a known side effect of dumping syndrome. So we are going to go outside of that. So we know that someone can have dumping syndrome and it can cause a variety of different symptoms with diarrhea being one of them. But we are going to exclude dumping syndrome from this discussion because that one is just obvious. And I want you to think outside the box.

Dawn: (01:08)                                                                                                                                                                                    So that’s where we’re going to dig into these seven different causes of diarrhea after bariatric surgery. So, first off, I want to clarify what is di.. Diarrhea anyway, what do we designate as diarrhea and I like to utilize the Bristol stool chart, and that is because it helps you kind of hone in and clarify what you really mean. So if you look at the Bristol stool chart and you can see it’s a number from one into seven.

Symptoms of diarrhea after bariatric surgery

Dawn : (01:54)
So from one that is.. That’s constipation and all the way down to seven is just watery diarrhea. So for the sake of this discussion, we are discussing, well, I guess I’ll, I will put this out there too. The best goal is to have for the perfect poop is number four. And then number three is a close second. So you would want to strive for those on a daily basis. Multiple times, at least once, if not three or more three times a day. So, but what we’re talking about for this discussion is we are talking about the numbers five through seven, so where it’s turning from a solid stool to more of a loose stool and into watery. So that’s where we’re focused to, with this discussion. I want to also kind of bring to light what can happen even before bariatric surgery.

Dawn: (02:56)
So this isn’t an uncommon thing for obesity in general. So some people experience this prior to even having bariatric surgery. But sometimes they worsen, you know, they just find that the symptoms worse are worse after bariatric surgery. So again and I, in all honesty we’ve even had people that improved. So they had diarrhea prior to surgery and they had bariatric surgery and it went away. Again, I think you just have to step back, look at the big picture and think about, okay, what’s been my pattern over the years and let that guide you.

Dawn: (03:37)                                                                                                                                                                                    But there was a Stu.. Study published in 2014 and they found the 8% of bariatric patients prior to surgery experienced diarrhea which is twice as high as seen in lean people. So again, I will cover some of these things that are common and some of them, it wouldn’t matter if you were overweight, obese, or lean this your size doesn’t play a role, but in other instances it does.

After Roux-en-Y gastric bypass with diarrhea after bariatric surgery

Dawn: (04:12)
So it’s just kind of just a little backstory that might help you kind of decide what’s really driving it. Why am I having diarrhea? And how am I going to get resolution, how am I going to improve this? So that’s why we are having this discussion. So seven causes a diarrhea after bariatric surgery. A study published in 2014 found that 75% of patients suffer from alterations in bowel habits and fecal transit time after Roux-en-Y gastric bypass with diarrhea being the most common symptom.

Dawn: (04:54)                                                                                                                                                                                    So you can kind of see, and they also included duodenal switch. So it’s the most diarrhea is the most common and usual symptom after gastric bypass and duodenal switch. That kind of leaves out the sleeve, but give me a moment and I will show you, there is opportunity for diarrhea within the sleeve community.

Dawn: (05:18)
So if you are having if you’ve had a gastric sleeve and you are having diarrhea don’t worry, we have things that could be driving it stick with me on these. What are the seven causes of diarrhea? Number one is malabsorption of carbohydrates. Number two, small intestinal bacterial overgrowth, or SIBO, C-diff Bile acid malabsorption, exocrine pancreatic insufficiency, dysbiosis, and a cholecystectomy or gallbladder removal. So let’s discuss the malabsorption of carbohydrates and here’s what we know. Certain carbohydrates are kind of associated with a poor absorption for some people.

Carbohydrates absorption after bariatric surgery

Dawn: (06:18)                                                                                                                                                                              These include the carbohydrates of like lactose and fructose sucrose and FODMAPs certain FODMaps for people, and those are the fermented oligosaccharide disaccharide, monosaccharide, and polyols. So it’s kind of a blend of different types of foods that can contribute to digestive distress. So when it comes to malabsorption of carbohydrates it’s unlikely to be urgent if it’s an urgent thing, there’s probably some additional underlying drivers with that.

Dawn: (06:48)
But if you’re having an intolerance to lactose or sucrose or fructose specifically from that food item, you’re going to notice it once it’s being digested. So you’re talking once you’re hitting maybe the hour, two hour mark, especially for bariatric patients especially like a, a roux-en-y gastric bypass you know, we throw in that dumping thing and that sugar will cause that quickly to occur. So you have to think more of dumping as the driver and not a malabsorption per se.

Dawn: (07:38)                                                                                                                                                                                    Although that is what’s happening it is usually going to be a little bit longer in time that if you’re having a, a carbohydrate malabsorption, it’s usually gonna be when, as you’re digesting the food. So hopefully that help you become aware and pay attention. You know, the best thing you can do for yourself, all of us, me included is pay attention to how food makes you feel.

Symptoms & experiences of diarrhea after bariatric surgery

Dawn: (07:56)
And if you know that, Hey, this doesn’t make me feel great. I have, you know, digestive issues. I have heartburn, I have diarrhea, I have bloating, I have gas whatever symptom that you are experiencing pay attention to that. Even just keeping a little notebook that you can jot it down and say, okay, this is what I had, and this is how much time it took for it to occur then just take the notes. And sometimes you yourself can identify what’s driving it.

Dawn: (08:48)                                                                                                                                                                                    Or if not, you can take it to your dietitian like myself. Somebody who’s trained in digestive issues and we can break it down and help you discover kind of, Hey, it, you know, it really sounds like you might be having a more specific issue with, you know, just grains or gluten. And because anytime you have a gluten containing grain, you have digestive symptoms.

Dawn: (09:03)
And matter of fact, I’ve had that happen with patients and I’ve had them do a food symptom survey and they document the food, they have the symptoms they experienced and the timing of it all. And we did identify that, Hey, gluten is a driver or things that contain gluten. You are having digestive issues after consuming those. So let’s get you tested for celiac disease and sure enough, they were positive. So again, I think it’s you are the only one living in your body, so we need your input.

Symptoms with carbohydrate & digestive issues after bariatric surgery

Dawn: (09:48)                                                                                                                                                                                    We need all those details to really make an, a super educated guess. Cause that is medicine that is healthcare. You have highly trained people who have seen you know, they have a a good understanding of a lot of different things in this category. So they can make some really good educated guesses and be right, you know, a lot of the times, but sometimes that’s why your provider sometimes misses it because we’re missing some of these details.

Dawn: (10:13)
It would be super helpful. So if you are having digestive issues start keeping like a food symptom survey and start documenting how foods are making you feel and that will help your provider and yourself come to the conclusion of what’s really driving it. back to carbohydrate malabsorption. Usually if you’re going to have a malabsorption of carbohydrates, it could, if you’re going to have it because of carbohydrate malabsorption, this can occur anywhere from, you know, one to eight hours depending on how your motility flows.

Dawn: (10:53)                                                                                                                                                                                    So if you have more of a slow digestive tract, it could be later. If yours is pretty rapid, then you might notice symptoms a little sooner. So what are the most common symptoms with carbohydrate mal absorption? These are things like gas, usually lots of gas bloating, diarrhea, abdominal discomfort.

SIBO after bariatric surgery

Dawn: (11:16)
So having those combination of symptoms can, you know, put a check box with carbohydrate malabsorption. That’s where you have to you know, understand all the different things that can cause it because you will soon see as I go through all seven of these that all these symptoms overlap. It’s, it’s easy to get confused. And that’s why working with a provider that can help you kind of hone in, in the right direction is usually pretty helpful.

Dawn: (12:16)                                                                                                                                                                                    So one underlying cause that can lead to a carbohydrate malabsorption is small intestinal bacteria overgrowth or SIBO. So SIBO can have a symptom of diarrhea. And we do see SIBO occur in the bariatric community quite a bit. And it can be a combination of different digestive issues, but diarrhea is definitely one of them. So a study published in 2017 reported that 15% of pre-surgery obese patients were positive for SIBO and then after surgery, it increased to about 40%.

Dawn: (12:41)
Now there are additional studies that go as high as 82% after bariatric surgery. So again, if you think of anywhere between 40 to 80% of you could have SIBO. Where diarrhea could be a symptom, you know, that’s a pretty big deal. So I think you have to pay attention to this and check that box of, okay, I have these symptoms and we need to rule this out. There’s three different types of SIBO.

Three diarrhea bariatric surgery types

Dawn: (13:16)                                                                                                                                                                                There’s a hydrogen hydrogen sulfide and methane. And the hydrogen and hydrogen sulfide are usually going to, you’re going to experience diarrhea. So, you know, knowing that you have diarrhea that would put you where you would wanna check box the SIBO as an option or a cause. Now a study published in 2020 compared Roux-en-Y gastric bypass, the omega bypass and sleeve gastrectomy patients. And they found that the risk for SIBO was the same across all three surgery types.

Dawn: (13:47)
So it didn’t matter which surgery you had, you all had the equal risks for getting SIBO or developing SIBO. But one interesting finding that they did notice was that the people who were positive for SIBO were more commonly older, females after a PPI treatment. So I find that interesting. That you know, SIBO and bariatric patients, driven with that PPI treatment. Because I just know how much PPIs are used in this community.

Symptoms for SIBO driven diarrhea 

Dawn: (14:16)                                                                                                                                                                                        I would encourage you to listen to one of my other videos and I’ll put the links in the show notes for this, where I discuss about low stomach acid and PPI use as a driver of SIBO. But that definitely puts you at a higher risk when you are taking PPIs for long periods of time. So some of the most common symptoms for SIBO driven diarrhea are abdominal pain, nausea, bloating, gas, diarrhea, malnutrition loss of appetite, and you get a full feeling really quickly at once you’ve eaten.

Dawn: (15:20)
So it doesn’t take you long to get full. That one is a little confusing with bariatric patients because that can also be an indication of stenosis or even an ulcer. So you have to vet those out. And work with a provider that can help you make sure that you’re covering all your bases and not you know, just going straight to a SIBO treatment when you have some other signs and red flags for maybe you have an ulcer stenosis. You know, to me, you would address those first and then we go in and we we lower that burden from SIBO. So the next one is C-diff. Clostridium difficile C-diff diarrhea. So C-diff is just a bacteria that causes diarrhea and then it also inflames the colon. So unfortunately C-diff is highly contagious and needs to be treated with importance.

Dawn: (16:22)
So there is an increased risk after bariatric surgery. Be. Actually a study published in 2019 did report the alteration of gastrointestinal climate caused by obesity, antibiotic therapy or surgery is a risk factor for C-diff. So this makes you vulnerable. And that combination of when you’re in the hospital, I mean, C-diff is all around you. Of course it’s everywhere. We’re exposed to, you know, C-diff and many other bacteria every day of our lives, which when you’re in a hospital setting you’re definitely more highly exposed.

Common signs of diarrhea after bariatric surgery

Dawn: (16:46)                                                                                                                                                                                      So those people who were hospitalized had to have some antibiotic therapy or maybe in combination with the surgery, it, it just puts you at a higher risk for developing C-diff. So what are the most common signs of C-diff? You’re gonna have watery diarrhea as often as 10 to 15 times a day.

Dawn: (17:28)
Abdominal cramping and pain, rapid heart rate, dehydration, fever, nausea. You know, that fever, I would say is a pretty big red flag if you’re having that many stools in a day. So you would want to contact your physician as quickly as possible and get the stool test so that you can rule that out and decide if you can move on. Because it can be very debilitating.

Dawn: (18:16)                                                                                                                                                                                    So if this happens right after bariatric surgery, where you are having, you know, multiple stools you know, every hour, that’s not normal even right after bariatric surgery. So you would want to discuss this with your surgeon immediately, for sure. One cool study published in 2019 did find that starting pro.. That starting probiotics within one to two days of the first dose of antibiotics in the hospital prevented C-diff infections.

Chronic diarrhea & antibiotics

Dawn: (18:31)
So something you could do for yourself is when you’re in the hospital, just take your probiotic with you and start taking that while you’re there. And that will that will protect you, that will help protect you for developing this. And anytime, if you ever got readmitted, just make sure you bring your probiotic with you. There are probiotics that do a better job with antibiotics. So I would you know, make sure you’re researching that.

Dawn: (19:16)                                                                                                                                                                                      I know our Ultimate gut restore is designed for this, for those to be taken with antibiotics. Now, when I say with, I mean, in the same day, not at the same time so you would separate those, but our Ultimate gut restore is perfect for antibiotic use. So it helps prevent those other infections and things that can occur. When you don’t take the probiotic, okay.

Dawn: (19:41)
The next one is bile acid diarrhea and bile acid diarrhea is just a common cause of chronic diarrhea. It’s characterized by excess bile acids within the colon. So how it kinda works is, you know, once you get to the end of your small intestines before you get into your colon usually those get those bile acids get recirculated back to your liver, and if they don’t and they get passed. So they’ll get reabsorbed in your small intestines and then get recycled back to your liver.

Colon & causes of diarrhea

Dawn: (20:16)                                                                                                                                                                                     If they don’t get reabsorbed and recycled, then guess what they are going to move into your colon. And then that’s where it’s going to cause you diarrhea. So when this happens the colon, the bile acids actually can influence colon motility and secretion. So that’s what leads to the diarrhea. When that.. When those too many bile acids enter the colon, then it can manage.

Dawn: (20:54)
So that’s when the motility speeds up and you have diarrhea. So if you here’s the tricky part with bile acid diarrhea there’s, if we wanna look at it, there’s three different causes or three different types of bile acid diarrhea. And one is structural. One is idiopathic and one is secondary. So the structural is usually surgical based. So something from surgery has contributed to this to cause a structural issue that now you can’t do that process on your own.

Bile acid diarrhea symptoms & experiences

Dawn: (21:16)                                                                                                                                                                                        Too much bile gets into the colon. The next is the idiopathic, and this is where you have increased bile acid production. They do feel there is a genetic base to this. So I think in time, maybe they will understand a little bit more, but you just, you produce more than you can manage. And then probably the most popular reason is the secondary causes.

Dawn: (22:02)
And those are because of a gall bladder removal, celiac disease chronic pancreatitis, microscopic colitis, and SIBO. All of those can cause the secondary bile acid diarrhea. So what would you experience if you were having bile acid diarrhea? So you would, you would notice frequent stools and urgent stools. You might actually have accidents so you can have stool accidents or incontinence. You can even have where you actually poop in the middle of the night while you’re sleeping.

Dawn: (22:26)                                                                                                                                                                                    So it’s called nocturnal defecation where you actually poop while you’re sleeping and then excessive gas and abdominal pain. So if you’re having those symptoms, you would wanna discuss this with your provider, your bariatric surgeon, or your bariatric team, and that you might have a bile acid malabsorption happening that’s causing this bile acid diarrhea. And because you know that you’re having frequent stools, sometimes it can be just in the morning time for some people they’ll notice.

Dawn: (23:19)
First thing in the morning that that’s when they have the diarrhea later in the day or after other meals, they don’t notice diarrhea. It, it changes at that point, but the morning is the worst for them. Or they just have a hard time making it to the bathroom before having accidents. So again, if you are having accidents or you are pooping while you’re sleeping, you want to think about bile acid diarrhea as a cause.

Bile acid malabsorption & risks for diarrhea

Dawn: (24:16)                                                                                                                                                                                Now we’ll kind of slide right into the gall, the gallbladder removal causing diarrhea. Because this is a form of bile acid malabsorption. So once you have your gallbladder removed bile acid management changes. So this can lead to that secondary Bile acid malabsorption. Your liver is where bile is produced. Your gallbladder is where the bile is concentrated and stored. And once that storage facility is gone, so you have your gallbladder removed, then your liver just has this chronic drip of bile.

Dawn: (24:28)
And it just kind of then gets triggered when you eat. So a little bit more gets released. That’s where some people might just have too much and they need some type of binder, some type of fiber to, to bind it up so that they don’t pass it into their colon. So that’s where it can help. You know, of course there’s bile acid binders that your doctor sometimes prescribes after having your gallbladder removed. And you can talk to them about that and that’s one easy way that you can kind of get resolution to it.

Dawn: (25:00)                                                                                                                                                                                       I wouldn’t say they’re always perfect, but there are multiple options. So if that doesn’t work then trying, you know, a different avenue would be advised. So the most common symptoms for, bil.. From having gall.. Your gallbladder removed and having diarrhea from it. You’ll notice that you have food, fatty food intolerance, nausea, vomiting, heartburn, gas, indigestion, diarrhea intermittent episodes of abdominal pain, probably do.. Depending on the dose of your fatty foods.

Dawn: (25:41)
And then some people, if they have like a gallstone stuck, they could have jaundice. So, you know, having your gallbladder removed does put you at a risk for diarrhea. And learning how to manage that and knowing what you can do to prevent the symptoms or stop the symptoms is key. So working with a provider like myself, who can give you options and alternatives so that you can have normal stools is ideal.

 Pancreatic exocrine insufficiency after bariatric surgery

Dawn: (26:16)                                                                                                                                                                                  The next one is exocrine pancreatic insufficiency or EPI. It’s also known as PEI or pancreatic exocrine insufficiency. I use EPI as my description. I like that. I’ve seen research in describing it both ways with PEI and EPI. So if you see that in documents, then you will know it means the same thing. Essentially it’s just, you know, identifying it in a, in a different way, the same thing in a different way.

Dawn: (26:51)
But exocrine pancreatic insufficiency is an insufficient secretion of pancreatic enzymes and sodium bicarbonate. And it is a known complication after any upper gastrointestinal surgeries. So this can cause big issues and it does require enzyme therapy. So there are things that you have to do before each meal to make sure that you’re going to be able to absorb the nutrition and digest it and not have severe amounts of diarrhea. But what’s the connection with bariatric surgery.

Dawn: (27:36)                                                                                                                                                                                        More and more studies are showing the prevalence of EPI after bariatric surgery. And I will tell you there it’s, I would say most of them are in the Roux-en-Y gastric bypass, but they do know that having a gastrectomy. I can influence exocrine function. So I would say we don’t necessarily see it as much in sleeve patients. And there was actually a study published in 2019 that found that sleeve gastrectomy actually relieves EPI.

Symptoms for EPI diarrhea after bariatric surgery

Dawn: (28:16)
So is it possible for someone with a gastric sleeve to have EPI? Sure. I think you have to look at you as a person and your whole health history, but is the sleeve going to protect you? I would say maybe. It is going to maybe put the odds in your favor that you may not develop EPI. But that doesn’t mean that you wouldn’t want to rule that out if you’re really having a lot of the symptoms for it. So let’s discuss that. So what are the symptoms for EPI? Usually it’s abdominal pain, gas and bloating diarrhea, and then fatty stools. They’re usually going to be oily, foul smelling, and it’s going to float. And then a lot of people, if it’s severe enough, they’re going to have some weight loss with that. The last one is dysbiosis and dysbiosis.

Dawn: (29:17)
If you have followed me, I have kind of discussed this many, many times and DYS dysbiosis is an imbalance in your gut bacteria, and this can be from too little good bacteria, too much bad bacteria or too much bacteria in the wrong location. So SIBO is dysbiosis. So we’ve already identified SIBO dysbiosis as a cause of diarrhea, but you also have to think about too much bad bacteria as a cause of diarrhea.

Dawn: (30:00)                                                                                                                                                                                  This form the overgrowth of bad stuff the bad bacteria is dysbiosis and it can be an overgrowth of pathogens or parasites which can come from your food supply, your environment, or traveling. Just making sure that you don’t forget about this piece is important. Because if you have a parasite, a low level of a parasite that you got traveling years ago, that really was never identified. Tr.. You know, doing a SIBO treatment will likely not give you resolution, even though it’s dysbiosis, it’s not gonna give you resolution because you’re not really solving the problem.

SIBO treatment & after bariatric surgery

Dawn: (30:45)
So you really have to dig into is it just SIBO or is there additional bacteria that is driving it? So if you’ve done a SIBO treatment and you haven’t resolved your issues that’s when I definitely like to do a GI map stool test. Because it can detect the DNA of pathogens and parasites even at low levels.  Cause it’s, it’s dealing with the DNA. It’s not the active you know, level or overgrowth that it’s quantifying it’s the DNA presence that it’s quantifying.

Dawn: (31:34)                                                                                                                                                                                      So,  that’s why it’s important to maintain a healthy gut after bariatric surgery because it can help you be more resilient to preventing these pathogens and parasites for, from taking over. And like I’ve discussed in some of my other videos, you know, having adequate stomach acid. I talk about this on my “Gastric surgery and heartburn considerations”. And we talk about stomach pH and we talk, we talk about how this influences your ability to protect yourself.

Low stomach acid and PPI overgrowth after bariatric surgery

Dawn: (32:00)
And there are many studies showing that, you know, low stomach acid and PPI use are connected to having an overgrowth of pathogens and parasites. So that’s where I think, you know, working with a provider like myself, that can really help sift through all your symptoms and really help give you relief, but then also dig deep enough that you can figure out what is driving it correct that problem and then you can get permanent relief that way you aren’t just you know, putting a bandaid over it with the treatment options, you are actually getting to the root and solving it.

Dawn: (32:25)                                                                                                                                                                                    So then you don’t need these things lifelong. You don’t need these bandaid solutions to make you feel better to give you relief right away. You don’t need those forever. Those are intended for short term to get you through the treatment protocol, when it comes to diarrhea. You have to really, in my opinion, your best resource is to do a food symptom survey and start documenting what’s happening.

Dawn: (33:17)
The timing of it, the severity of it, all the symptoms that come with it. And cause usually bowel movements come after eating because that’s that normal process. So, that’s where you document that information and it can give you a good foundation of information especially for your provider to really help you get to what’s driving this diarrhea problem. So, I really hope this has given you some ideas to consider in ways to think about, Hey, you know what? I am having diarrhea pretty frequently and I do notice it maybe in the morning time or only after breakfast, but I don’t have it any other time of day. That’s where you want to document that stuff, write that down. And another thing that I think is helpful to understand is that say you do have EPI or you have bile acid diarrhea.

EPI diarrhea & there solutions of diarrhea after bariatric surgery

Dawn: (34:25)
So those two specifically can get kind of tricky because SIBO can cause bile acid diarrhea and EPI can SIBO. So you again, that’s where getting to that root cause. You may think okay. I have SIBO, but in reality you actually have bile acid diarrhea or you actually have EPI. And maybe you treat the EPI and you feel better, but not all the way better. The reason why it could be that you need a SIBO protocol.

Dawn: (35:16)                                                                                                                                                                                  you need to treat the SIBO before you’re going to correct, or you’re going to lessen the EPI diarrhea. So, if you are having chronic diarrhea and you have . You know like I mentioned, all of these symptoms kind of overlap, they have very similar symptoms. So it gets confusing to know this is why working with a provider who understands digestive health . And can help you sort through all of these symptoms and really help you identify what is driving your diarrhea.

Dawn: (35:43)
So I really hope this has helped. And please reach out if you, you know, just click the link in any my bios. If you are really struggling with diarrhea there are solutions which is for diarrhea after bariatric surgery . There are things you can do that can really help get this under control and give you your life back. I would say when it comes to diarrhea this one is probably the most troublesome because it interferes with your life. If it’s happening multiple times a day, if you’re having multiple stools a day, urgently especially. It, it disrupts your life and that’s where it’s important to get help.

Conclusion of diarrhea after bariatric surgery

Dawn: (36:30)                                                                                                                                                                               Don’t be afraid to get second opinions and third opinions and trial different resources. Because there are many options for all of these. And just because the first one didn’t work, that doesn’t mean you don’t wanna try option three, four or five.  I really hope this has given you some thoughts if you are struggling with diarrhea. I hope you find that one of these causes is at the root of it . And you work with someone that can help you resolve it and get things back in balance. So you guys have a great day and we will talk to you next time.  Bye.
Your future health awaits…