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Chapter 53
Diarrhea After Duodenal Switch: Medical
andSurgical Management
BarbaraJ.Allen andPatrickW.Domkowski
Bariatric surgery has emerged as the primary treatment for chronic morbid obesity
disease in the United States and the world. The data supporting the health improvement and reduction in BMI are indisputable. However as more and more people
undergo bariatric surgery, the prevalence of certain sequelae following surgery is
also becoming more evident. One of these problems that can have a direct impact on
the quality of life is diarrhea. The reasons for it after bariatric surgery are numerous
and sometimes challenging to treat.
Chronic diarrhea, although infrequent, can become a debilitating problem for
patients after bariatric surgery and in particular the duodenal switch.
Bariatric surgery does alter bowel function. The effects are in part determined by
the type of bariatric surgery performed. The effects of altered bowel function may
also be acute, meaning within the rst month of surgery or more chronic in nature,
affecting function years later. Diarrhea is one specication manifestation of altered
bowel function. Moreover, it has a spectrum of presentation with respect to stool
consistency and frequency.
The World Health Organization denes diarrhea as three or more (frequency)
loose bowel movement a day. Diarrhea is usually dened as three basic categories:
watery, fatty (malabsorptive), and inammatory. For our purposes we will focus on
fatty or malabsorptive diarrhea. Diarrhea can also present as a spectrum to several
inconvenient loose bowel movements a day to the other extreme of more than 20
watery bowel movements daily with no ability to leave your house.
Despite the signicant effectiveness of the duodenal switch (DS) in ameliorating
morbid obesity disease and many of its comorbid conditions, it is yet to be widely
adopted by bariatric surgeons or embraced by patients seeking bariatric surgery. The
B. J. Allen · P. W. Domkowski (*)
Sebastian River Medical Center, Sebastian, FL, USA
e-mail: Barbara.Allen@Steward.org; Patrick.Domkowski@Steward.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
A. Teixeira et al. (eds.), Duodenal Switch and Its Derivatives in Bariatric and
Metabolic Surgery, https://doi.org/10.1007/978-3-031-25828-2_53
493
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B. J. Allen and P. W. Domkowski
DS is performed in less than 1% of all bariatric surgeries worldwide. When evaluating the risk benet analysis for the DS, many providers and/or patients may be dissuaded against the procedure due to concerns for diarrhea. This chapter will review
the pathophysiology of the DS and its impact on diarrhea. It will also review medical and surgical management of diarrhea postoperatively.
53.1 Diarrhea
Alterations in bowel function can be expected after DS surgery due to the anatomical changes. The average number of bowel movements per day following the DS is
2–3 [1]. Diarrhea is generally accepted to be the passage of three or more loose or
liquid stools per day or more frequent passage than is normal for the individual.
Diarrhea is generally considered to be one of the commonly accepted operative
risks associated with DS surgery as there is a sixfold increase in diarrhea postoperatively [2]. DS patients report higher incidence of bowel movements, atus, and
urgency [2]. Patients with severe diarrhea may also experience dehydration, nutritional deciencies, physical discomfort, and changes in quality of life.
Diarrhea can be acute lasting 1 or 2days, persistent lasting longer than 2weeks
but less than 4weeks, or chronic lasting more than 4weeks. Diarrhea can be categorized as watery, fatty (malabsorptive), or inammatory. This chapter will focus
more on malabsorptive causes of diarrhea. However, when completing your history
and physical exam, it is important to consider other sources that may be causing or
exacerbating postsurgical diarrhea.
53.2 Pathophysiology ofDuodenal Switch andDiarrhea
The basic anatomical changes associated with the duodenal switch are the restriction caused by the sleeve gastrectomy portion of the surgery and alterations in
metabolism caused by the biliopancreatic diversion. The sleeve gastrectomy restricts
calorie intake and food choices. Because it is pylorus sparing, it is not associated
with “dumping syndrome.” There is a decrease in acidity of gastric contents, but the
sleeve anatomy generally does not have much impact on bowel function. However,
by diverting food from the proximal to the distal gut, there is an impact on intestinal
hormone secretion, decreased fat absorption, and creation of short gut syndrome. It
is generally accepted that the common channel length of 100cm produces the same
weight loss with lesser diarrhea and decreased protein deciency compared to a
50cm common channel [3]. Although it is individually variable, over time the body
will naturally improve absorption of fat until it reaches a new equilibrium [3].
Therefore, consideration of surgical intervention for diarrhea is not generally recommended until after the rst year [4].
In normal anatomy, the presence of fat in the duodenum causes the release of
the gut hormone, cholecystokinin (CCK), which slows gastric motility and
53 Diarrhea After Duodenal Switch: Medical andSurgical Management
495
emptying, stimulates pancreatic enzymes release, and causes contraction of the
gallbladder with subsequent release of lecithin and bile salts [3]. Lipid digestion
and absorption is affected by the diversion of the biliopancreatic limb. Shortening
of the common channel can lead to incomplete absorption of dietary fat. Excessive
levels of bile acids in the lower gastrointestinal tract may cause diarrhea via one or
more mechanisms: altering water and sodium transport; increasing lower gastrointestinal motility; damaging the mucosa; inducing mucus secretion; or stimulating
defecation [5]. Fatty acids that are not broken down are passed directly into the
colon. Undigested fat leads to lose and frequent bowel movements that may be
often hard to control and associated with cramping, foul-smelling diarrhea, and
lots of gas.
The diversion of the biliopancreatic limb also affects digestion of starches and
complex carbohydrates. Decreased exposure to amylase in the GI tract decreases
the time that carbohydrates can be broken down into simple sugars for absorption.
In normal anatomy, starch exposed to pancreatic and digestive enzymes is nearly
completely hydrolyzed before it has passed beyond the duodenum and the upper
jejunum [3]. Many patients report onset of lactose intolerance following bariatric
surgery. Incomplete carbohydrate absorption can lead to an increased osmotic load
of sugar, with an augmented intraluminal volume (water) and a consequent acceleration of intestinal passage. Gas production and diarrhea occur in connection with
the bacterial ora in the colon, the unabsorbed sugar presenting as a substrate for
increased bacterial fermentation [6]. Ingestion of sugar alcohols which are not well
absorbed in the GI tract can also lead to fermentation and subsequent GI upset with
bloating, gas, and diarrhea. The most common forms are sorbitol, mannitol, xylitol, and maltitol. The microvilli of the small intestine further digest starch and
other dietary carbohydrates. Over time, the GI tract can compensate with thicker
and more efcient villi to counteract the malabsorption and decrease GI symptoms. Another factor contributing to diarrhea is the presence of relatively undigested food passing rapidly through the gastrointestinal tract creating irritation in
the ileum [4].
There is reason to believe that bariatric surgery including the DS alters the neuronal and hormonal signaling pathways that regulate pancreatic secretions. The
symptoms of pancreatic exocrine insufciency (PEI) steatorrhea, weight loss, maldigestion, and malabsorption are expressed in both patient populations. Although
clinical studies are lacking, it is appropriate to consider pancreatic enzyme replacement therapy in the management of post DS diarrhea [7].
53.2.1 Evaluation ofDiarrhea
53.2.1.1 History
Evaluation relies heavily on the patient history. Have the patient describe the onset
of symptoms, frequency, and consistency of the stool as well as other associated
symptoms like urgency, fever, bloating, abdominal pain, blood, or mucus in the
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B. J. Allen and P. W. Domkowski
stool. Patients with diarrhea often report fatigue, dizziness, nausea, unplanned
weight loss, low urine output, or concentrated urine. Include dietary history and
look for potential triggers like sugar alcohols, fatty foods, caffeine, and alcohol. Ask
about recent travel and employment (daycare worker, food handler). Review medication list for drugs commonly associated with diarrhea. Do not forget to assess the
impact symptoms have on the patient’s quality of life. Having three bowel movements a day has a different impact on an ofce worker versus an over the road truck
driver. Some patients report meal skipping behaviors because eating triggers
diarrhea.
53.2.2 Physical Exam
The primary focus of the physical exam is to assess for evidence of dehydration,
malabsorption, or its sequela. Alterations in general appearance (lethargy), skin
turgor, mucous membranes, and vital signs (include orthostatic vitals) are signs of
dehydration related to diarrhea. Evidence of muscle wasting, hair loss, ascites,
ecchymoses (vitamin K deciency), temporal wasting, angular cheilitis, glossitis,
and peripheral edema is indicative of malabsorption. A general abdominal exam
is warranted especially if there are complaints of abdominal pain to rule out an
acute abdominal process. If the patient is experiencing neuromuscular signs of
muscle weakness or convulsions, severe electrolyte abnormalities are to be
suspected.
53.2.3 Testing
It is reasonable to suspect malabsorption in patients with diarrhea following the
DS. The most frequent causes are protein, fat, and carbohydrate malabsorption.
However, chronic or persistent diarrhea following the DS could be related to deciency in zinc or selenium ([8, 9], p.197). While there is no specic serologic test
for malabsorption, laboratory tests are helpful to identify specic deciencies or
complications from malabsorption as well as other potential causes of diarrhea.
Based on patient history and physical exam, laboratory testing may include CBC,
CMP, prealbumin, vitamin B12, folate, 25-hydroxyvitamin D, lipid panel, prealbumin, prothrombin time, carotene, methylmalonic acid, zinc, and selenium. Refer to
Table53.1 for serologic lab testing.
Stool specimens may be helpful to evaluate diarrhea related to surgical malabsorption and to rule out other causes (Table53.2). Stool tests can be utilized to document fat malabsorption, which is the most sensitive indicator among the
macronutrients to identify global malabsorption. Fecal fat can be performed by
53 Diarrhea After Duodenal Switch: Medical andSurgical Management
Table 53.1 Serologic lab testing
Test Evaluate for Findings
CBC Anemia due to iron deciency or
vitamin B12 or folate deciency
Serum iron, total iron
binding capacity
Vitamin B12, folate Vitamin deciency Decreased
CMP Protein deciency, electrolyte
Magnesium Malabsorption Decreased
Prealbumin Malnutrition Decreased
Lipid panel Malabsorption Decreased—cholesterol,
Carotene Fat malabsorption Decreased
25-Hydroxyvitamin D Fat malabsorption vitamin D Decreased
Prothrombin time Fat malabsorption vitamin K Increased
Methylmalonic acid Early indicator of vit. B12
Zinc Malabsorption Decreased
Selenium Malabsorption Decreased
Iron deciency Decreased
imbalances, and organ function
deciency
Microcytic anemia—iron
deciency
Macrocytic anemia—vit B12 or
folate malabsorption
Dehydration—hematocrit
elevated
Protein malabsorption—
decreased protein, albumin,
calcium
Dehydration—elevated BUN/Cr,
potassium, sodium
Diarrhea—decreased potassium,
sodium, magnesium, CO
triglycerides
Increased
497
2
completing a qualitative assessment on a single specimen or a quantitative analysis
that requires 72-h fecal fat collection. Instruct patients to consume a normal amount
(80–100g/day) of fat before and during the collection. A fecal fat excretion of >7g/
day indicates fat malabsorption or pancreatic exocrine insufciency (PEI).
The hydrogen breath test can be used to detect carbohydrate malabsorption as
well as small intestine bacterial overgrowth. Glucose hydrogen breath test is more
acceptable for diagnosis of small intestinal bacterial overgrowth (SIBO), whereas
lactose and fructose hydrogen breath tests are used for detection of lactose and fructose maldigestion, respectively [9].
Sometimes Zollinger Ellison’s syndrome (ZES) presents with diarrhea and no
other symptoms. If this is suspected at a gastrin level 10 times, the normal ndings
are suggestive of ZES and require further workup.
It is important to remember that patients with a DS have normal gastric emptying. This was studied. They found that over 80% of patients had normal gastric
emptying.
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Table 53.2 Stool specimen testing
Test fecal Evaluate for Findings
Culture If bacterial infection is suspected Bacteria
Clostridium
difcile toxin
Ova and parasites Ova and parasites suggested for
Fecal occult
blood
Stool for white Inammatory intestinal disease Positive
Fecal calprotectin Inammation Elevated in inammatory bowel
Fecal
fat—qualitative
Fecal fat—
quantitative (72-h
collection)
Elastase PEI Decreased
Clostridium difcile especially for
patients with diarrhea after
hospitalization or following
antibiotic therapy
those with a history of travel or
camping
Suspected malignancy Positive
Fat malabsorption Positive
Fat malabsorption or PEI Greater than 7g/day
B. J. Allen and P. W. Domkowski
• Campylobacter species
• Salmonella species
• Shigella species
Positive
Positive
disease, bacterial infections, some
parasitic infections, and colorectal
cancer
Decreased in irritable bowel syndrome
and viral infections
53.3 General Management ofDiarrhea
The goals of management include treating the underlying disease, optimizing the
control of diarrhea, identifying and treating nutritional deciencies, monitoring for
recurrence, and optimizing quality of life.
53.3.1 Medical Management ofDiarrhea Related
toNutrient Malabsorption
• Have patients complete a food diary and symptom tracker to identify trig-
ger foods.
• Serum laboratory testing to evaluate for dehydration and determine degree of
malabsorption as well as vitamin and mineral deciencies. Serum laboratory
testing will also be completed to monitor patient progress (Table53.1).
53 Diarrhea After Duodenal Switch: Medical andSurgical Management
499
• Consider testing to conrm the source of malabsorption (fecal fat, hydrogen
breath test, lactose tolerance test) (Table53.2).
• Nutritional consult for dietary education based on above ndings.
• Nutritional support to ensure appropriate protein (80–120 g/day) and
caloric intake:
– Oral nutrition is preferred with food and/or protein shakes.
– In severe cases, parenteral or enteral supplementation may be warranted. Use
caution when initiating high concentrations of dextrose to prevent refeeding
syndrome.
– If prolonged parenteral or enteral supplementation is required, surgical inter-
vention is considered.
• Ensure adequate hydration:
– Water, sugar-free sports drinks, non-caffeinated beverages.
– IV hydration is especially helpful when diarrhea is severe or is associated
with nausea and vomiting. Infuse normal saline and consider infusing a
banana bag (multivitamin, thiamine, folic acid) if indicated. Do not infuse
dextrose until a thiamine deciency is ruled out.
• Replacement of vitamin and mineral deciencies.
• Exocrine pancreatic insufciency:
– Pancrelipase microencapsulated, delayed release (e.g., creon). Initially 30,000
USP units lipase with meals and half of that amount with snacks; adjust gradually to patient needs. Recommended for patients with intact upper GI tract
and intact gastric secretions.
– Pancrelipase, non-microencapsulated (e.g., Viokace). Initially 30,000 USP
units lipase with meals and half of that amount with snacks; adjust gradually
to patient needs. Inactivated by stomach acid. Use in patients lacking acidpeptic gastric environment or administered with acid-suppressing drugs
([10], p.11).
• Bile acid malabsorption is usually determined through empirical treatment and
resolution of symptoms rather than through testing:
– Cholestyramine 4 g once daily initially; increase gradually (weekly) to four
divided doses; maximum, 36g/day ([10], p.11).
– Please note there is a potential for reduced absorption of other drugs and
supplements, and therefore cholestyramine should be administered either 1h
before or 4–6h after other medications.
– Unfortunately, use of cholestyramine for chronic diarrhea due to bile acid
malabsorption is currently an off-label use and is not always covered by
insurance.
• Antidiarrheals can be used to slow transit time and assist with symptom
management:
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B. J. Allen and P. W. Domkowski
– Begin with loperamide and advance to diphenoxylate and atropine if needed.
– A dose of loperamide at bedtime can decrease the number of early morning
bowel movements. It may also delay the onset in those who have been previously awakened early in the morning by urgent bowel movements [4].
– Caution patients that cases of torsades de pointes, cardiac arrest, and death
have been reported with the use of a higher than recommended dosage of
loperamide.
• Small intestinal bacterial overgrowth:
– The use of antibiotics to treat the symptomatic patient with SIB0 is the cor-
nerstone of therapy ([11], p.172).
Ciprooxacin and metronidazole are commonly used.
Amoxicillin–clavulanic acid, doxycycline, and trimethoprim–sulfamethoxazole may also be considered.
Rifaximin use is limited by its high cost.
– Nutritional support and correction of nutritional deciencies is an important
step in managing SIBO since it is not only associated with malabsorption but
can cause malabsorption and vitamin deciencies ([11], p.170).
– Although a diet low in fermentable oligo-, di-, and monosaccharides and
polyols (FODMAP) has been shown to improve bloating and gas in patients
with irritable bowel syndrome, there is no strong evidence to support its recommendation in patients with SIBO.
– It is common practice to consider probiotics in the treatment of SIBO.Although
a small study on Roux-en-Y gastric bypass surgery patients supported the use
of probiotics to improve bacterial overgrowth [12], the use of probiotics in the
duodenal switch patient is largely empiric.
53.3.2 Patient Education
Having 2–3 bowel movements a day is considered normal.
Complete a food diary and symptom tracker to help identify dietary causes of
diarrhea. There are even downloadable apps that can help track dietary intake and
bowel patterns. Use of dietary tracking apps to monitor intake of macronutrients
(carbohydrates, fats, ber, proteins, and water) provides data that can help with
symptom management and self-care.
Restrict fat to less than 50 g/day.
Whenever possible, eliminate or avoid trigger foods. Ingest triggers foods with
or after other foods to increase tolerance.
Read labels to avoid sugar alcohols (sorbitol, mannitol, xylitol, and maltitol).
If lactose intolerant, consider lactose-free milk or addition of lactase. Lactase
should be taken with your rst bite of food or drink.
53 Diarrhea After Duodenal Switch: Medical andSurgical Management
501
Use quality protein supplements as needed to meet a protein goal of 80–120 g
daily. Whey isolate protein supplements have little to no lactose. Don’t drink protein shakes too fast.
Avoid more than one serving a day of caffeine containing beverages.
Avoid full strength sugar sweetened beverages. If consumed dilute with water in
a 1:1 ratio.
Compliance with nutritional supplements and lab monitoring is critical to preventing/managing nutritional deciencies and therefore diarrhea.
Stay hydrated. The general recommendation of maintaining hydration with 64
ounces of uid daily may not be adequate in the presence of high-water loss with
diarrhea. If additional uids are needed, consider supporting electrolytes with a
sugar-free sports drink.
53.3.2.1 Surgical Treatment ofDiarrhea
The biliopancreatic diversion (BPD) with the duodenal switch (DS) as described by
Hess and Hess in 1998 remains one of the most effective bariatric surgeries for
short- and long-term reduction in body mass index as well as amelioration of type
II diabetes, one of the diseases most commonly associated with obesity disease
[13]. However due to its technical difculties and purported post-surgical nutritional deciencies, it has yet to be widely adapted into mainstream bariatric surgeries. Among these side effects are possible protein malnutrition and diarrhea. As
reported in the original paper by Hess and Hess in 1998, the length of the common
channel was between 50 and 100cm. This is why it is critical for the DS patient to
consume 90–100 g of protein daily.
If diarrhea persists even after both dietary modications and prescription medications have been exhausted, then surgical revision may be an option. There are
several case reports in the literature of patients that have had successful elimination
of their diarrhea through revisionary surgery.
However, it is important to note that the perception that the duodenal switch may
cause more frequent bowl habits compared to other bariatric surgeries is not true. A
study by Wasserberg and colleagues compared the bowel habits of gastric bypass
patients to duodenal switch patients. Although the duodenal switch is associated
with more bowel episodes than the bypass, the difference was not statistically signicant [14]. Fysekidis and colleagues reported that the average number of bowel
movements per day for 43 pre-op patients was 1.9 [15]. Postoperatively the frequency of bowel habits was measured at different time intervals and compared with
preoperative values. Six months after surgery, the average number was 2.7. Twelve
months following surgery that was 2.6 and 36months was 2.8. None of these measured time points were signicantly different to the preoperative number.
In another study, Sovik and colleagues did a comparative study on the duodenal
switch and the gastric bypass effects on bowel habits [16]. They had followed up at
1 and 2 years after surgery, and participants were surveyed. They reported an
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B. J. Allen and P. W. Domkowski
increase in both the amount of bowel habits and anal leakage following the switch
compared to the gastric bypass.
The concept of revising a bariatric surgery due to refractory diarrhea is not
unique to the duodenal switch. Revisional surgeries have also been in gastric bypass
patients. In 2012, Appresai and Murr reported the lengthening of the common channel in a gastric bypass patient suffering with chronic diarrhea and decreased quality
of life [17]. The patient had an original distal gastric bypass with a 150cm reported
common channel. At the time of the revisionary surgery, 50 additional centimeters
was switched from the biliopancreatic limb to the alimentary limb. This ameliorated
the diarrhea and returned the patients serum albumin to above 3 g/dL.Therefore, the
length of the common channel and thus the absorptive intestinal surface area appears
to be the chief determinant in frequency of diarrhea.
This has been reported with “very very long” limb bypasses where the common
channel is shorter [18]. Nelson and colleagues reported this name for their surgery.
The Roux limb was made between 300 and 500cm with a 100cm common channel
that the incidence of diarrhea signicantly and negatively impacting the quality of
life was 4%. All of these patients required surgical revision to increase the length of
the common channel 100–200cm. This surgical maneuver increases the absorptive
capacity of the small intestine, thereby increasing serum albumin and water absorption, thus leading to less diarrhea. Physiologically, this increases the surface area of
absorption and thereby effectively eliminates the diarrhea in these refractory cases.
The fact that there are only case reports in the surgical literature speaks to their rarity.
Conceptually the surgery involves lengthening the common channel. However, it
is by denition considered revisional bariatric surgery and therefore must be undertaken with an even greater level of hyper vigilance. Most importantly, the intestinal
limbs must be correctly identied before anything transacted and re-anastomosed.
In the BPD-DS, this would include identifying the alimentary limb, the biliopancreatic limb, and the common intestinal channel. Typically, the common intestinal
channel in the DS is between 50 and 100cm in length. Increasing it to 150–200cm
will generally increase absorption of nutrients enough to eliminate the diarrhea.
A variation of the traditional duodenal switch is the single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S) [19]. This is a potentially a promising alternative to the traditional duodenal switch with purported less gastrointestinal
sequel. Nonetheless, a concern of this variation is the chronic diarrhea and potential
hypoproteinemia. A single site experience reported a 6-year experience with the
SADI-S.Horsey and colleagues reported a signicantly reduced number of average
bowel movements from 9 to 2.6 with common channel lengthening with the
SADI-S.Since this is a loop switch, the duodenal ileostomy has to be redone.
As reected in the published literature, the vast majority of patients with diarrhea
can be managed medically through a combination or dietary modications and
medications. In those refractory cases, surgery can be performed to decrease malabsorption by returning more small bowel intestinal length to the food stream.
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