Disease of the digestive system. Postgastrectomy problems--II.

(Last week Mr. Williams considered the cause and management of some symptoms arising after partial gastrectomy. The article continues with an account of other common complaints.) Loss of Weight Many patients lose weight or fail to gain weight after gastrectomy. Those who are undernourished at the time of the operation seem to be at the greatest risk. Some degree of malabsorption of food is common after gastrectomy. It is only a malabsorption of fats that is important. Carbohydrate digestion and absorption as judged by xylose and glucose absorption tests are almost always normal. Although intestinal intubation studies have suggested that protein digestion is impaired by gastrectomy, it is unknown for protein deficiency to occur as the result of gastrectomy provided that oral intake is normal and there is no excess loss. Mal-absorption of fat is the easiest form of malabsorption to detect, as the residuum is passed relatively unaltered and can be measured in the faeces. The normal person on an average intake excretes in the faeces no more than five grammes of fat per day. After partial gastrectomy the average daily output of fat in the faeces is from seven grammes (with a Billroth I anastomosis) to ten grammes (with a Billroth II anastomosis). It is the diminished intake that is the most important cause of weight loss after gastrectomy. The causes of the diminished intake are: lack of appetite, early satiation after a small quantity of food, and fear of provoking postcibal symptoms. The analysis of these three factors is the initial step in the evaluation and treatment of weight loss. Appetite.-This is determined by a number of apparently unrelated factors, including low blood sugar, empty stomach, and feeling of mental and physical wellbeing. The patient may have a poor appetite because he takes too much tobacco or alcohol or because he is deficient in minerals or vitamins. Iron deficiency is particularly likely to impair the appetite, so to a lesser extent do deficiencies of vitamin B12 and folic acid. In the correct evaluation of the postgastrectomy patient all these factors must be assessed. Treatment may not be easy, particularly of those patients who poison themselves with nicotine or alcohol. For those who suffer from, but do not deserve, a poor appetite even after the correction of deficiencies some form of gastric stimulation before meals may be advised. The French gastroenterologist will advocate a glass of wine, the …