Mr Khokan Roy, 30 yr resident of Bhyander came in emergency with complaints of pain in abdomen & vomiting since 3 days. So far he was taking treatment from a local general practitioner, who just gave him medicines thinking it to be acidity problem. Patient tolerated pain hoping to get better with his family doctor's medicines. but his condition slowly deteriorated in next two days as he continued to vomit & have increasing pain in abdomen. Clinical examination of this patient was sufficient to reach to the diagnosis of acute appendicitis. Subsequently his sonography confirmed that there was swelling in appendix. He was explained about the disease and prepared for emergency surgery – removal of the appendix. He was offered options of open appendectomy as well as key hole (laparoscopic) surgery. He said that he would not be able to take long leave and thus opted for Laparoscopic appendectomy. The operative findings were that the appendix had burst & lot of pus had formed around appendix. Waiting for three days had caused the appendix to burst and spread of pus. The surgery was carried out successfully – removal of the appendix along with the pus. A drainage tube was placed for couple of days to let out the inside toxins. The patient made a rapid & uneventful recovery & the wounds healed very well..
Although appendix is situated in right lower abdomen, the initial manifestation of the disease can be upper or central abdominal pain. This is called refereed pain. Often such patients are diagnosed & treated for acidity. Important time is lost and such appendix are prone to rupture and cause more trouble to patient. A proper clinical examination along with the aid of ultrasonography can prevent such disasters.

Introduction
Gastro-oesophageal reflux disease (GORD) is a common condition where stomach acid leaks out of the stomach and into the oesophagus (gullet). The oesophagus is a long tube of muscle than runs from the mouth to the stomach.
Common symptoms of GORD include:
Heartburn – burning chest pain or discomfort that occurs after eating
An unpleasant sour taste in the mouth – caused by stomach acid coming back up into the mouth (known as regurgitation)
Dysphagia – pain and difficulty swallowing
Many people experience occasional episodes of GORD, but if people have persistent and reoccurring symptoms it is normally regarded as a condition that needs treatment.
Treatment
A step-by-step approach is usually recommended for GORD. This means that relatively uncomplicated treatments, such as changing your diet, will be tried first.
If this fails to help control symptoms then a person can be 'stepped up' to more complex treatments such as antacids, which help neutralise the effects of stomach acid.
In cases where medication fails to control symptoms, surgery may be required.
Causes
It is thought that GORD is caused by a combination of factors. The most important factor is the lower oesophageal sphincter (LOS) muscle not working properly.
The LOS acts like a valve, opening to let food fall into the stomach and closing to prevent acid leaking out of the stomach and into the oesophagus. In cases of GORD, the LOS does not close properly, allowing acid to leak up, out of the stomach.
Known risk factors for GORD include:
Being overweight or obese
Being pregnant
Eating a high-fat diet
Complications
A common complication of GORD is that the stomach acid can irritate and inflame the lining of the oesophagus, which is known as oesophagitis.
In severe cases of oesophagitis, ulcers (open sores) can form which can cause pain and make swallowing difficult.
A rarer and more serious complication of GORD is cancer developing inside the oesophagus (oesophageal cancer).
Who is affected
GORD is a common digestive condition. It is estimated that one in five people will experience at least one episode of GORD a week, and that 1 in 10 people experience symptoms of GORD on a daily basis.
GORD can affect people of all ages, including children. However, most cases affect adults aged 40 or over. GORD is thought to affect both sexes equally, but males are more likely to develop complications.
Outlook
The outlook for GORD is generally good, and most people respond well to treatment with medication.
However, relapses are common, with around half of people experiencing a return of symptoms after a year. As a result, some people may require a long-term course of medication to control their symptoms.
Symptoms of gastro-oesophageal reflux disease
The three most common symptoms of gastro-oesophageal reflux disease (GORD) are:
Heartburn
Regurgitation of acid into your throat and mouth
Dysphagia (difficulty swallowing
These symptoms are discussed in more detail below.
Heartburn
Heartburn is a burning pain or a feeling of discomfort that develops just below your breastbone. The pain is usually worse after eating, or when bending over or lying down.
Regurgitation
Regurgitation of acid usually causes an unpleasant, sour taste at the top of your throat or the back of your mouth.
Dysphagia
Around one in three people with GORD has problems swallowing (dysphagia). It can occur if the stomach acid causes scarring of the oesophagus, which leads to the oesophagus narrowing, making it difficult to swallow food.
People with GORD-associated dysphagia say it feels like a piece of food has become stuck somewhere near their breastbone.
Less common symptoms of GORD
GORD can sometimes have a number of less common symptoms associated with the irritation and damage caused by stomach acid.
Less common symptoms of GORD include:
Feeling sick
Persistent cough, often worse at the night
Chest pain
Wheezing
Tooth decay
Laryngitis (inflammation of the larynx), which causes throat pain and hoarseness
If you have asthma and GORD, your asthma symptoms may get worse as a result of stomach acid irritating your airways.
When to seek medical advice
If you are only experiencing symptoms such as heartburn once or twice a month, then you probably do not need to seek treatment from Dr. B C Shah.
You should be able to control symptoms by making a number of lifestyle changes and using over-the-counter medication as and when symptoms occur.
You should see Dr. B C Shah if you are having frequent or severe symptoms and finding yourself using over-the-counter medication on a weekly or daily basis. You may require prescription medication to control symptoms and prevent complications.
Causes of gastro-oesophageal reflux disease
It is thought that most cases of gastro-oesophageal reflux disease (GORD) are caused by a problem with the lower oesophageal sphincter (LOS) muscle. The LOS is located at the bottom of the oesophagus (gullet), the tube that runs from the back of the throat to the stomach.
The LOS works in a similar way to a valve. It opens to let food into your stomach, and it closes to prevent acid leaking back up into your oesophagus.
However, in people with GORD, the LOS can become weakened, which allows stomach acid to pass back into the oesophagus. This causes symptoms of heartburn, such as a burning pain or a feeling of discomfort in your stomach and chest.
Exactly what causes the LOS to become weakened is not always clear, but a number of risk factors have been identified.
These are outlined below.
Risk factors
Being overweight or obese – this can place an increased pressure on your stomach, which in turn can weaken the LOS
Having a diet high in fatty foods – the stomach takes longer to dispose of stomach acids after digesting a fatty meal
Consuming tobacco, alcohol, coffee, or chocolate – it has been suggested that these four substances may relax the LOS
Being pregnant – changes in hormone levels during pregnancy can weaken the LOS and increase pressure on your stomach
Having a hiatus hernia – a hiatus hernia is where part of your stomach pushes up through your diaphragm (the sheet of muscle used for breathing)
Stress
There is also a condition called gastroparesis, where the stomach takes longer to dispose of stomach acid. The excess acid can push up through the LOS.
Gastroparesis is common in people who have diabetes, because high blood sugar levels can damage the nerves that control the stomach.
Medication
There are a number of medications that can relax the LOS, leading to the symptoms of GORD.
These include:
Calcium-channel blockers – a type of medication used to treat high blood pressure
Non-steroidal anti-inflammatory drugs (NSAIDs) – a type of painkiller, such as ibuprofen
Selective serotonin reuptake inhibitors (SSRIs) – a type of antidepressant
Corticosteroids (steroid medication) – which are often used to treat severe symptoms of inflammation
Bisphosphonates – used to treat osteoporosis(weakening of the bones)
Nitrates – a medication used to treat angina (a condition that causes chest pain)
Diagnosing gastro-oesophageal reflux disease
In most cases, Dr. B C Shah will be able to diagnose gastro-oesophageal reflux disease (GORD) by asking questions about your symptoms.
Further testing for GORD is usually only required if:
You have dysphagia (difficulty swallowing)
Your symptoms do not improve despite taking medication
Further testing aims to confirm or disprove the diagnosis of GORD while checking for any other possible causes of your symptoms, such as irritiable bowel syndrome.
Endoscopy
An endoscopy is a procedure where the inside of your body is directly examined using an endoscope.
An endoscope is a long, thin flexible tube that has a light source and video camera at one end so that images of the inside of your body can be sent to an external monitor.
To confirm a diagnosis of GORD, the endoscope will be inserted into your mouth and down your throat. The procedure is usually done while you are awake, and you may be given a sedative to help you to relax.
An endoscopy is used to check whether the surface of your oesophagus has been damaged by stomach acid. It can also rule out more serious conditions that can also cause heartburn, such as stomach cancer.
Manometry
If an endoscopy does not find any evidence of damage to your oesophagus, you may be referred for a further test called manometry.
Manometry is used to assess how well your lower oesophageal sphincter (LOS) is working by measuring pressure levels inside the sphincter muscle.
During manometry, one of your nostrils will be numbed using a topical anaesthetic. A small tube will then be passed down your nostril and into your oesophagus to the site of the LOS. The tube contains a number of pressure sensors, which can detect the pressure generated by the muscle, then send the reading to a computer.
During the test, you will be asked to swallow some food and liquid to check how effectively your LOS is functioning.
A manometry test takes around 20 to 30 minutes to complete. It is not painful, but you may have minor side effects including:
A nosebleed
A sore throat
However, these side effects should pass quickly once the test has been completed.
Manometry can be useful for confirming a diagnosis of GORD, or for detecting less common conditions that can disrupt the normal workings of the LOS, such as muscle spasms or achalasia (a rare swallowing disorder).
Barium swallow
If you are experiencing symptoms of dysphagia then you may be referred for a test known as a barium swallow.
The barium swallow test is one of the most effective ways of assessing your swallowing ability and finding exactly where the problems are occurring. The test can often identify blockages or problems with the muscles used during swallowing.
As part of the test, you will be asked to drink some barium solution. Barium is a non-toxic chemical that is widely used in tests because it shows up clearly on an X-ray. Once the barium moves down into your upper digestive system, a series of X-rays will be taken to identify any problems.
If you need to have a barium meal X-ray, you will not be able to eat or drink anything for at least six hours before the procedure so that your stomach and duodenum (top of the small intestine) are empty. You may be given an injection to relax the muscles in your digestive system.
You will then lie down on a couch and your specialist will give you a white, chalky liquid to drink which contains barium. As the barium fills your stomach, your specialist will be able to see your stomach on an X-ray monitor, as well as any ulcers or abnormal growths. Your couch may be tipped slightly during the test so that the barium fills all the areas of your stomach.
A barium swallow usually takes about 15 minutes to perform. Afterwards you will be able to eat and drink as normal, although you may need to drink more water to help flush the barium out of your system. You may feel slightly sick after a barium meal X-ray, and the barium may cause constipation. Your stools may also be white for a few days afterwards as the barium passes through your system.
24-hour pH monitoring
If the manometry test cannot find problems with your oesophageal sphincter muscles, another test known as 24-hour pH monitoring can be used (pH is a unit of measurement used in chemistry, and describes how acidic a solution is). The lower the pH level, the more acidic the solution is.
The 24-hour pH monitoring test is designed to measure pH levels around your oesophagus. You should stop taking medication used to treat GORD for seven days before having a 24-hour pH test because the medication could distort the test results.
During the test, a small tube containing a probe will be passed through your nose to the back of your oesophagus. This is not painful but can feel a little uncomfortable.
The probe is connected to a portable recording device about the size of an MP3 player, which you wear around your wrist. Throughout the 24-hour test period, you will be asked to press a button on the recorder every time you become aware of your symptoms.
You will be asked to complete a diary sheet by recording when you have symptoms upon eating. Eat as you normally would to ensure an accurate assessment can be made.
After the 24-hour period is over, the probe will be removed so measurements on the recorder can be analysed. If test results indicate a sudden rise in your pH levels after eating, a confident diagnosis of GORD can usually be made.
Treating gastro-oesophageal reflux disease
A number of self-care techniques may help relieve symptoms of gastro-oesophageal reflux disease (GORD). They are described below.
If you are overweight, losing weight may help reduce the severity and frequency of your symptoms because it will reduce pressure on your stomach.
If you are a smoker, consider quitting. Tobacco smoke can irritate your digestive system and may make symptoms of GORD worse.
Eat smaller, more frequent meals, rather than three large meals a day. Make sure you have your evening meal three to four hours before you go to bed.
Be aware of triggers that make your GORD worse. For example, alcohol, coffee, chocolate, tomatoes, or fatty or spicy food. After you identify any food that triggers your symptoms, remove them from your diet to see whether your symptoms improve.
Raise the head of your bed by around 20cm (8 inches) by placing a piece of wood, or blocks under it. This may help reduce your symptoms of GORD. However, make sure your bed is sturdy and safe before adding the wood or blocks. Do not use extra pillows because this may increase pressure on your abdomen.
If you are currently taking medication for other health conditions, check with DR. B C Shah to find whether he may be contributing to your symptoms of GORD. Alternative medicines may be available. Do not stop taking a prescribed medication without consulting Dr. B C Shah first.
Medication
A number of different medications can be used to treat GORD. These include:
Over-the-counter medications
Proton-pump inhibitors (PPIs)
H2-receptor antagonists
Prokinetics
Depending on how your symptoms respond, you may only need medication for a short while or alternatively on a long-term basis.
These are described below.
Over-the-counter medications
A number of over-the-counter medicines can help relieve mild to moderate symptoms of GORD.
Antacids are medicines that neutralise the effects of stomach acid. However, antacids should not be taken at the same time as other medicines because they can stop other medicines from being properly absorbed into your body. They may also damage the special coating on some types of tablets. Ask Dr. B C Shah for advice.
Alginates are an alternative type of medicine to antacids. They work by producing a protective coating that shields the lining of your stomach and oesophagus from the effects of stomach acid.
Proton-pump inhibitors (PPIs)
If GORD fails to respond to the self-care techniques described above, Dr. B C Shah may prescribe a one month course of proton-pump inhibitors (PPIs) for you. PPIs work by reducing the amount of acid produced by your stomach.
Most people tolerate PPI well and side effects are uncommon.
When they do occur they are usually mild and may include
Headaches
diarrhoea
feeling sick
abdominal pain
constipation
dizziness
skin rashes
In order to minimise any side effects, Dr. B C Shah will prescribe the lowest possible dose of PPIs that they think will be effective in controlling your symptoms. Therefore, inform Dr. B C Shah if he can prescribe PPIs for you that prove ineffective. A stronger dose may be needed.
Sometimes, the symptoms of GORD can return after a course of PPIs has been completed. Go back to see Dr. B C Shah if you have further or persistent symptoms.
In some cases you may need to take PPIs on a long-term basis.
H2-receptor antagonists
If PPIs cannot control your symptoms of GORD, another medicine known as an H2-receptor antagonist (H2RA) may be recommended to take in combination with PPIs on a short-term basis (two weeks), or as an alternative to them.
H2RAs block the effects of the chemical histamine, used by your body to produce stomach acid. H2RAs therefore help reduce the amount of acid in your stomach.
Side effects of H2RAs are uncommon. However, possible side effects may include:
Diarrhoea
Headaches
Dizziness
Tiredness
A rash
Some types of H2RAs are available as over-the-counter medicines. These types of HR2As are taken in a lower dosage than the ones available on prescription. Ask Dr. B C Shah if you are not sure whether these medicines are suitable for you.
Prokinetics
If your GORD symptoms are not responding to other forms of treatment, Dr. B C Shah may prescribe a short-term dose of a prokinetic.
Prokinetics speed up the emptying of your stomach, which means there is less opportunity for acid to irritate your oesophagus.
A small number of people who take prokinetics have what is known as ‘extrapyramidal symptoms’. Extrapyramidal symptoms are a series of related side effects that affect your nervous system. Extrapyramidal symptoms include:
Muscle spasms
Problems opening your mouth fully
A tendency to stick your tongue out of your mouth
Slurred speech
Abnormal changes in body posture
If you have the above symptoms while taking prokinetics, stop taking them and contact Dr. B C Shah or out-of-hours doctor immediately. He may recommend your dose is discontinued.
Extrapyramidal symptoms should stop within 24 hours of the medicine being withdrawn.
Prokinetics are not usually recommended for people under 20 years old because of an increased risk of extrapyramidal symptoms.
Surgery
Surgery is usually only recommended in cases of GORD that fail to respond to the treatments listed above.
Alternatively, you may wish to consider surgery if you have persistent and troublesome symptoms but do not want to take medication on a long-term basis.
While surgery for GORD can help relieve your symptoms, there are some associated complications that may result in you developing additional symptoms, such as:
Dysphagia (difficulty swallowing)
Flatulence
Bloating
An inability to belch (burp)
Discuss the advantages and disadvantages of surgery with Dr. B C Shah before making a decision about treatment.
Surgical procedures that are used to treat GORD include:
Laparoscopic nissen fundoplication (LNF)
Endoscopic injection of bulking agents
Endoluminal gastroplication
Endoscopic augmentation with hydrogel implants
Endoscopic radiofrequency ablation
These procedures are discussed below.
Laparoscopic nissen fundoplication (LNF)
Laparoscopic nissen fundoplication (LNF) is one of the most common surgical techniques used to treat GORD.
LNF is a type of keyhole surgery that involves the surgeon making a series of small incisions (cuts) in your abdomen (tummy). Carbon dioxide gas is then used to inflate your abdomen to give the surgeon room to work in.
During LNF, the surgeon will wrap the upper section of your stomach around your oesophagus and staple it in place. This will contract (tighten) your lower oesophageal sphincter (LOS), which should prevent any acid moving back out of your stomach.
LNF is carried out under general anaesthetic, which means you will not feel any pain or discomfort. The surgery takes 60 to 90 minutes to complete.
After having LNF, most people can leave hospital once they have recovered from the effects of the general anaesthetic. This is usually within two to three days. Depending on the type of job you do, you should be able to return to work within three to six weeks.
For the first six weeks after surgery, it is recommended you only eat soft food, such as mince, mashed potatoes or soup. Avoid eating hard food that could get stuck at the site of the surgery, such as toast, chicken or steak.
Common side effects of LNF include:
Dysphagia (difficulty swallowing)
Belching
Bloating
Flatulence
These side effects should resolve over the course of a few months. However, in about 1 in 100 cases they can be persistent. In such circumstances, further corrective surgery may be required.
New surgical techniques
In the last decade, a number of new surgical techniques have been introduced for the treatment of GORD.
All techniques discussed below are non-invasive, which means no incisions need be made into your body. Therefore, they can usually be performed under local anaesthetic on a day surgery basis, so you should not have to spend the night in hospital.
Endoscopic injection of bulking agents
Endoscopic injection of bulking agents involves the surgeon using an endoscope to find the site where stomach and oesophagus meet (known as the gastro-oesophageal junction).
A thin tube called a catheter is then passed down the endoscope, and used to inject a combination of plastic and liquid into the junction. This narrows the junction and helps to prevent acid leaking up from the stomach.
The most common side effect of this type of surgery is mild to moderate chest pain. This develops in around a half of all cases.
Other side effects include:
Dysphagia
Feeling sick
High temperature of 38ºC (100.4ºF) or above
These side effects should resolve within a few weeks.
Endoluminal gastroplication
Endoluminal gastroplication involves the surgeon using an endoscope to sow a series of pleats (folds) into the LOS. The pleats should restrict how far the LOS can open, preventing acid leaking up from your stomach.
Side effects of this type of surgery include:
Chest pain
Abdominal (tummy) pain
Vomiting
Sore throat
These side effects should improve within a few days.
Endoscopic augmentation with hydrogel implants
Endoscopic augmentation with hydrogel implants is a similar technique to an endoscopic injection, except the surgeon uses hydrogel to narrow your gastro-oesophageal junction. Hydrogel is a type of flexible plastic gel very similar to living tissue.
The most common complication arising from this procedure is that the hydrogel starts to come out of the gastro-oesophageal junction. One study found this happened in one in five cases. However, this is a relatively new technique and success rates may well improve in future.
Endoscopic radiofrequency ablation
In endoscopic radiofrequency ablation, the surgeon passes a balloon down an endoscope to the site of your gastro-oesophageal junction. The balloon is then inflated.
Tiny electrodes are attached to the outside of the balloon and small pulses of heat generated. This creates small scars in the tissue of your oesophagus, causing it to narrow and making it more difficult for stomach acid to leak out of your stomach.
Out of all the new surgical techniques mentioned, there is little known about the safety of endoscopic radiofrequency ablation. Possible complications and side effects may include:
Chest pain
Dysphagia
Injury to the oesophagus
LINK Reflux Management System
A new type of surgery introduced in 2011, is the LINK Reflux Management System.
This type of keyhole surgery uses magnetic beads to reinforce the LOS muscle.
The magnetic force of the beads helps keep the LOS closed when at rest, preventing stomach acid leaking upwards. The LOS opens normally when swallowing.
This type of surgery appears effective and safe in the short-term but as it is a new technique, its long-term effectiveness and safety are unclear.
Complications of gastro-oesophageal reflux disease
Oesophageal ulcers
The excess acid produced by gastro-oesophageal reflux disease (GORD) can damage the lining of your oesophagus (oesophagitis) which can lead to the formation of ulcers. The ulcers can bleed, causing pain and making swallowing difficult. Ulcers can usually be successfully treated by controlling the underlying symptoms of GORD.
Medications used to treat GORD can take several weeks to become effective, so it is likely Dr. B C Shahwill recommend additional medication to provide short-term relief from your symptoms.
Two types of medication that can be used are:
antacids to neutralise stomach acid on a short-term basis
alginates, which produce a protective coating on the lining of your oesophagus
Both antacids and alginates are over-the-counter medications available from pharmacists. The pharmacist will advise you on the types of antacid and alginate most suitable for you.
Antacids are best taken when you have symptoms, or when symptoms are expected, such as after meals or at bedtime. Alginates are best taken after meals.
Side effects for both medications are uncommon but include:
diarrhoea
vomiting
flatulence
Oesophageal stricture
Repeated damage to the lining of your oesophagus can lead to the formation of scar tissue. If the scar tissue is allowed to build up, it can cause your oesophagus to become narrowed. This is known as oesophageal stricture.
An oesophageal stricture can make swallowing food difficult and painful. Oesophageal strictures can be treated by using a tiny balloon to dilate (widen) the oesophagus. This procedure is usually carried out under a local anaesthetic.
Barrett’s oesophagus
Repeated episodes of GORD can lead to changes in the cells lining of your lower oesophagus. This is a condition known as Barrett’s oesophagus.
It is estimated that 1 in 10 people with GORD will develop Barrett’s oesophagus. Most cases of Barrett’s oesophagus first develop in people aged 50-70 years old. The average age at diagnosis is 62.
Barrett’s oesophagus does not usually cause noticeable symptoms other than those associated with GORD.
The concern is that Barrett’s oesophagus is a pre-cancerous condition. This means that while changes in the cells are not cancerous, there is a small risk they could develop into ‘full blown’ cancer in the future. This would then trigger the onset of oesophageal cancer (see below).
Oesophageal cancer
Risk factors that increase the risk of cells in the lining of your oesophagus turning cancerous include:
Being male
Having the symptoms of GORD for longer than 10 years
Having three or more episodes of heartburn and related symptoms a week
Smoking
Obesity
If it is thought that you have an increased risk of developing oesophageal cancer, it is likely you will be referred for regular endoscopies to monitor the condition of the affected cells.
If oesophageal cancer is diagnosed in its initial stages, it is usually possible to cure the cancer using a treatment called photodynamic therapy (PDT).
PDT involves injecting your oesophagus with a medication that makes it sensitive to the effects of light. A laser attached to an endoscope is then placed inside your oesophagus and burns away the cancerous cells.

Weight loss can be tricky. We can become victims of our own success. When you are able to lower your calorie intake on a consistent basis and lose weight, you will most likely reach a plateau. That plateau where the scale just seems to be stubborn and stuck at the same number for weeks at a time. Our body does this when calories are restricted because the metabolism begins to slow down to match the calorie intake. When you hit a plateau it is easy to become psychologically demoralized and begin to question the diet, hard work and sacrifice. Do not panic.This is a normal phenomena with losing weight and is a natural part of the weight loss process.
Following weight loss surgery, patients may lose weight fairly rapidly at first and then as time passes the weight loss becomes more gradual. Commonly, weight will stabilize at about 18 months after Roux en Y gastric bypass and duodenal switch. During these 18 months weight loss does not follow a predictable trend, but can be erratic with alternating periods of significant weight loss followed by no weight loss. Charting this weight loss may give the appearance of a stairway. It is not uncommon for patients to question why their weight loss has stalled at times and wonder if they are doing something wrong or if the surgery has not worked for them. This same trend can be seen after LAGB, however the weight loss will be more gradual and steady, averaging 5-10 lbs per month but continuing upto 3 yrs. Plateaus may occur if the band is not tightened, and therefore if this happens, the patient should consult with their surgeon for possibly a band adjustment.
Day to day or even week to week, fluctuations in weight loss occur due to many factors beyond just loss of fat mass. Water weight is probably the most common cause of this variability. This depends upon one's hydration status. Other factors besides fat mass that may result in inaccurate weights are current contents of the GI tract, gaining muscle mass and menstrual cycle in females. It is , thus recommended that patients should not weigh themselves too frequently. Exercise frequency and intensity may result in weight loss plateaus. An increase in meal frequency to high grazing or a decrease in frequency by starving during day and binge eating at night may also reduce one's ability to lose weight.
For surgeries that have malabsorptive component, the GI tract will adapt overtime to its new anatomic change. This adaptation may allow for better absorption of the consumed food, especially fats, reducing the benefits of surgery. Unfortunately nothing short of a further surgery can avert the adaptation effect. However, adhering to small meals high in protein may limit this effect. Anatomic factors exist which may limit one's ability to lose weight. With the RYGB, the size of the gastric pouch may change overtime. If it enlarges, it will accomodate larger meals. In addition, anastomotic dilation between stomach pouch may allow quicker emptying of the pouch reducing its effect on satiety and potential weight loss. Once dilation occurs, they cannot be reversed, and correction can only be obtained through surgical revision. With gastric band, the stoma may widen due to weight loss , at which point the band should be tightened with an adjustment. Weight loss can be resumed after this. For the same reason, after GB ,a patient should not drink during meals. This activity will result in more rapid transition of solid food from the gastric pouch eliminating the sensation of fullness and resulting in ingestion of larger portions.
In general it is normal to have periods of plateaus through all phases of weight loss after surgery. Recognize this plateaus as being normal. Don't focus on the scales too often. Adhering to the basic rules of eating correctly and exercising regularly may shorten the duration of a plateau and lead ultimately to greater longterm weight loss, improved balance, improved self confidence, and overall improved sense of well being.

The gut contains < 200 mL of gas, whereas daily gas expulsion averages 600 to 700 mL after consuming a standard diet plus 200 g of baked beans. About 75% of flatus is derived from colonic bacterial fermentation of ingested nutrients and endogenous glycoproteins. Gases include hydrogen (H2), methane (CH4), and carbon dioxide (CO2). Flatus odor correlates with H2 sulphide concentrations. Swallowed air (aerophagia) and diffusion from the blood into the lumen also contribute to intestinal gas. Gas diffuses between the lumen and the blood in a direction that depends on the difference in partial pressures. Thus, most nitrogen (N2) in the lumen originates from the bloodstream, and most H2 in the bloodstream originates from the lumen.

Etiology

There are 3 main gas-related complaints: excessive belching, distention (bloating), and excessive flatus, each with a number of causes (see Table 11: Symptoms of GI Disorders: Some Causes of Gas-Related Complaints). Infants 2 to 4 mo of age with recurrent crying spells often appear to observers to be in pain, which in the past has been attributed to abdominal cramping or gas and termed colic. However, studies show no increase in H2 production or in mouth-to-cecum transit times in colicky infants. Hence, the cause of infantile colic remains unclear (see Approach to the Care of Normal Infants and Children: Colic).

Excessive belching: Belching (eructation) results from swallowed air or from gas generated by carbonated beverages. Aerophagia occurs normally in small amounts during eating and drinking, but some people unconsciously swallow air repeatedly while eating or smoking and at other times, especially when anxious or in an attempt to induce belching. Excessive salivation increases aerophagia and may be associated with various GI disorders (eg, gastroesophageal reflux disease), ill-fitting dentures, certain drugs, gum chewing, or nausea of any cause.

Most swallowed air is eructated. Only a small amount of swallowed air passes into the small bowel; the amount is apparently influenced by position. In an upright person, air is readily belched; in a supine person, air trapped above the stomach fluid tends to be propelled into the duodenum. Excessive eructation may also be voluntary; patients who belch after taking antacids may attribute the relief of symptoms to belching rather than to antacids and may intentionally belch to relieve distress.

Distention (bloating): Abdominal bloating may occur in isolation or along with other GI symptoms in patients with functional disorders (eg, aerophagia, nonulcer dyspepsia, gastroparesis, irritable bowel syndrome) or organic disorders (eg, ovarian cancer, colon cancer). Gastroparesis (and consequent bloating) also has many nonfunctional causes, the most important of which is autonomic visceral neuropathy due to diabetes; other causes include postviral infection, drugs with anticholinergic properties, and long-term opiate use. However, excessive intestinal gas is not clearly linked to these complaints. In most healthy people, 1 L/h of gas can be infused into the gut with minimal symptoms. It is likely that many symptoms are incorrectly attributed to “too much gas.”

On the other hand, some patients with recurrent GI symptoms often cannot tolerate small quantities of gas: Retrograde colonic distention by balloon inflation or air instillation during colonoscopy often elicits severe discomfort in some patients (eg, those with irritable bowel syndrome) but minimal symptoms in others. Similarly, patients with eating disorders (eg, anorexia nervosa, bulimia) often misperceive and are particularly stressed by symptoms such as bloating. Thus, the basic abnormality in patients with gas-related symptoms may be a hypersensitive intestine. Altered motility may contribute further to symptoms.

Excessive flatus: There is great variability in the quantity and frequency of rectal gas passage. As with stool frequency, people who complain of flatulence often have a misconception of what is normal. The average number of gas passages is about 13 to 21/day. Objectively recording flatus frequency (using a diary kept by the patient) is a first step in evaluation.
Sidebar 1

Essay on Flatulence


(First printed in the 14th Edition of The Merck Manual)


Flatulence, which can cause great psychosocial distress, is unofficially described according to its salient characteristics: (1) the “slider” (crowded elevator type), which is released slowly and noiselessly, sometimes with devastating effect; (2) the open sphincter, or “pooh” type, which is said to be of higher temperature and more aromatic; (3) the staccato or drumbeat type, pleasantly passed in privacy; and (4) the “bark” type (described in a personal communication) is characterized by a sharp exclamatory eruption that effectively interrupts (and often concludes) conversation. Aromaticity is not a prominent feature. Rarely, this usually distressing symptom has been turned to advantage, as with a Frenchman referred to as “Le Petomane,” who became affluent as an effluent performer who played tunes with the gas from his rectum on the Moulin Rouge stage.





Flatus is a metabolic byproduct of intestinal bacteria; almost none originates from swallowed air or back-diffusion of gases (primarily N2) from the bloodstream. Bacterial metabolism yields significant volumes of H2, CH4, and CO2.

H2 is produced in large quantities in patients with malabsorption syndromes and after ingestion of certain fruits and vegetables containing indigestible carbohydrates (eg, baked beans), sugars (eg, fructose), or sugar alcohols (eg, sorbitol). In patients with disaccharidase deficiencies (most commonly lactase deficiency), large amounts of disaccharides pass into the colon and are fermented to H2. Celiac disease, tropical sprue, pancreatic insufficiency, and other causes of carbohydrate malabsorption should also be considered in cases of excess colonic gas.

CH4 is also produced by colonic bacterial metabolism of the same foods (eg, dietary fiber). However, about 10% of people have bacteria that produce CH4 but not H2.

CO2 is also produced by bacterial metabolism and generated in the reaction of HCO3– and H+. H+ may come from gastric HCl or from fatty acids released during digestion of fats—the latter sometimes produces several hundred mEq of H+. The acid products released by bacterial fermentation of unabsorbed carbohydrates in the colon may also react with HCO3– to produce CO2. Although bloating may occasionally occur, the rapid diffusion of CO2 into the blood generally prevents distention.

Diet accounts for much of the variation in flatus production among individuals, but poorly understood factors (eg, differences in colonic flora and motility) may also play a role.

Despite the flammable nature of the H2 and CH4 in flatulence, working near open flames is not hazardous. However, gas explosion, even with fatal outcome, has been reported during jejunal and colonic surgery and colonoscopy, when diathermy was used during procedures in patients with incomplete bowel cleaning.

Table 11

Some Causes of Gas-Related Complaints

Cause
Suggestive Findings
Diagnostic Approach

Belching

Aerophagia (swallowing air)
With or without awareness of swallowing air

Sometimes in patients who smoke or chew gum excessively

Sometimes in patients who have esophageal reflux or ill-fitting dentures
Clinical evaluation

Gas from carbonated beverages
Beverage consumption usually obvious based on history
Clinical evaluation

Voluntary
Patient usually admits when questioned
Clinical evaluation

Distention or bloating

Aerophagia
See Belching
Clinical evaluation

Irritable bowel syndrome
Chronic, recurrent bloating or distention associated with a change in frequency of bowel movements or consistency of stool

No red flag findings

Typically beginning during the teens and 20s
Clinical evaluation

Examination of stool

Blood tests

Gastroparesis
Nausea, abdominal pain, sometimes vomiting

Early satiety

Sometimes in patients known to have a causative disorder
Upper endoscopy and/or nuclear scanning that evaluates stomach emptying

Eating disorders
Long-standing symptoms

In patients who are thin but still very concerned about excess body weight, particularly young women
Clinical evaluation

Constipation if chronic
A long history of hard, infrequent bowel movements
Clinical evaluation

Non-GI disorders (eg, ovarian or colon cancer)
New, persistent bloating in middle-aged or older patients

For colon cancer, sometimes blood in stool (blood may be visible or detected during a doctor's examination)
For ovarian cancer, pelvic ultrasonography

For colon cancer, colonoscopy

Flatus

Dietary substances, including beans, dairy products, vegetables, onions, celery, carrots, Brussels sprouts, fruits (eg, raisins, bananas, apricots, prune juice), and complex carbohydrates (eg, pretzels, bagels, wheat germ)
Symptoms that develop mainly after consuming food that can cause gas
Clinical evaluation

Trial of elimination

Disaccharidase deficiency
Bloating, cramps, and diarrhea after consuming milk products
Breath tests

Celiac disease (eg, celiac sprue, tropical sprue)
Symptoms of anemia, steatorrhea, loss of appetite, diarrhea

For celiac sprue,weakness, symptoms that often begin during childhood

For tropical sprue, nausea, abdominal cramps, weight loss
Blood tests

Biopsy of the small intestine

Pancreatic insufficiency
Diarrhea, steatorrhea

Usually a known history of pancreatic disease
Abdominal CT

Sometimes MRCP, endoscopic ultrasonography, or ERCP

MRCP = magnetic resonance cholangiopancreatography.




Evaluation

History: History of present illness in patients with belching should be directed at finding the cause of aerophagia, especially dietary causes.

In patients complaining of gas, bloating, or flatus, the relationship between symptoms and meals (both timing and type and amount of food), bowel movements, and exertion should be explored. Certain patients, particularly in the acute setting, may use the term "gas" to describe their symptoms of coronary ischemia. Changes in frequency and color and consistency of stool are sought. History of weight loss is noted.

Review of systems should seek symptoms of possible causes, including diarrhea and steatorrhea (malabsorption syndromes such as celiac sprue. tropical sprue, disaccharidase deficiency, and pancreatic insufficiency) and weight loss (cancer, chronic malabsorption).

Past medical history should review all components of the diet for possible causes (see Symptoms of GI Disorders: Some Causes of Gas-Related Complaints).

Physical examination: The examination is generally normal, but in patients with bloating or flatus, signs of an underlying organic disorder should be sought on abdominal, rectal, and (for women) pelvic examination.

Red flags: The following findings are of concern:

Weight loss

Blood in stool (occult or gross)

"Gas" sensation in chest

Interpretation of findings: Chronic, recurrent bloating or distention relieved by defecation and associated with change in frequency or consistency of stool but without red flag findings suggests irritable bowel syndrome.

Long-standing symptoms in an otherwise well young person who has not lost weight are unlikely to be caused by serious physiologic disease, although an eating disorder should be considered, particularly in young women. Bloating accompanied by diarrhea, weight loss, or both (or only after ingestion of certain foods) suggests a malabsorption syndrome.

Testing: Testing is not indicated for belching unless other symptoms suggest a particular disorder. Testing for carbohydrate intolerance (eg, lactose, fructose) with breath tests should be considered particularly when the history suggests significant consumption of these sugars. Testing for small-bowel bacterial overgrowth should also be considered, particularly in patients who also have diarrhea, weight loss, or both, preferably by aerobic and anaerobic culture of small-bowel aspirates obtained during upper GI endoscopy. Testing for bacterial overgrowth with H2 breath tests, generally glucose-H2 breath tests, is prone to false-positive (ie, with rapid transit) and false-negative (ie, when there are no H2-producing bacteria) results. New, persistent bloating in middle-aged or older women (or those with an abnormal pelvic examination) should prompt pelvic ultrasonography to rule out ovarian cancer.

Treatment

Belching and bloating are difficult to relieve because they are usually caused by unconscious aerophagia or increased sensitivity to normal amounts of gas. Aerophagia may be reduced by eliminating gum and carbonated beverages, cognitive behavioral techniques to prevent air swallowing, and management of associated upper GI diseases (eg, peptic ulcer). Foods containing unabsorbable carbohydrates should be avoided. Even lactose-intolerant patients generally tolerate up to 1 glass of milk drunk in small amounts throughout the day. The mechanism of repeated belching should be explained and demonstrated. When aerophagia is troublesome, behavioral therapy to encourage open-mouth, diaphragmatic breathing and minimize swallowing may be effective.

Drugs provide little benefit. Results with simethicone

, an agent that breaks up small gas
bubbles, and various anticholinergics are poor. Some patients with dyspepsia and postprandial upper abdominal fullness benefit from antacids, a low dose of tricyclic antidepressants (eg, nortriptyline

10 to 50 mg po once/day), or both to reduce visceral
hypersensitivity.

Complaints of excess flatus are treated with avoidance of triggering substances (see Table 11: Symptoms of GI Disorders: Some Causes of Gas-Related Complaints). Roughage (eg, bran, psyllium seed) may be added to the diet to try to increase colonic transit; however, in some patients, worsening of symptoms may result. Activated charcoal can sometimes help reduce gas and unpleasant odor; however, it stains clothing and the oral mucosa. Charcoal-lined undergarments are available. Probiotics (eg, VSL#3) may also reduce bloating and flatulence by modulating intestinal bacterial flora. Antibiotics are useful in patients with documented bacterial overgrowth.

Functional bloating, distention, and flatus may run an intermittent, chronic course that is only partially relieved by therapy. When appropriate, reassurance that these problems are not detrimental to health is important.

Key Points

Testing should be guided by the clinical features.

Be wary of new-onset, persistent symptoms in older patients.

It is not uncommon to see an abdominal ultrasonogram report suggesting stones in the gall bladder when you visit your doctor for pain in the upper abdomen or indigsetion or chronic gas. Stones in the gall bladder is a more serious condition than stones in the kidneys. The GB stones can cause infection in the gall bladder presenting with severe pain abdomen, can also cause jaundice by blocking the bile passage into the intestine and rarely a near fatal condition called acute pancreatitis by blocking the mouth of the pancreatic duct..
There is no medical treatment for gall bladder stones and these patients will require laparoscopic removal of the gall bladder along with the stones.
This surgery is performed as a day care procedure where in the patient checks into the hospital at5.00 am .Surgery is done at 6.00am and the patient is discharged at 2.00pm. Effectively the patient is in the hospital for about 6 hours. They walk back home and will take a normal dinner that night. Pain killer medications are given for relief of pain if any.. These patients start their routine normal activity the day following surgery. In the las t 100 such operations we performed ,we had no problems with any patient and none of them have been re-admitted to the hopital. So I believe that laparoscopic gall bladder remoban can be safely operated on a day care basis and there is absolutely no need for the patient to saty in the hospital overnight.