For many gastrectomy (removal of the stomach) patients, eating can be a source of much frustration and anxiety. However, with a little guidance and education, hopefully these negative feelings should be lessened.

There are many symptoms of having a gastrectomy, such as "dumping syndrome", diarrhoea, malabsorption and steatorrhoea (fatty stool). These can result in inadequate food intake and malabsorption, which may lead to nutritional deficiencies and weight loss. It therefore takes a lot of effort on your part to try and avoid these symptoms.

Dumping syndrome

Following gastric surgery, some patients who have had two thirds or more of the stomach removed (or whose procedure has included a vagotomy) may experience the dumping syndrome. With dumping syndrome, food is dumped into the small intestine (jejunum) about 10 to 15 minutes after ingestion, instead of being gradually released in small amounts. Some symptoms include abdominal fullness, nausea, dizziness, sweating, cramping and abdominal pain followed by diarrhoea within 15 minutes of eating. Other symptoms are feeling warm, weakness, faintness and a racing pulse. These symptoms are caused when concentrated sugar passes too rapidly from the stomach into the intestine. The body dilutes this sugar mixture by bringing fluid from body tissues into the intestine. The loss of water from tissues can produce a temporary drop in blood pressure, with resulting weakness and faintness. Lying down immediately after eating reduces these symptoms because food remains in the stomach for longer.

Hypoglycaemia

Food must be digested and broken into simple units, such as glucose (sugar), before it can be used for energy by the body. The sugar is absorbed into the blood and the body releases a hormone, insulin, whose job it is to get the glucose out of the blood and into the tissues and cells where it can be used. Normally the release of sugar from food is gradual which allows for a gradual release of insulin. However, with a rapid movement of food through the system, the sugar (glucose) is absorbed very quickly into the blood. This serves as a type of shock for the body and in response extra insulin is produced. When the supply of insulin outweighs the amount of sugar, the blood sugar levels drop low (hypoglycaemia). Symptoms of postmeal hypoglycaemia such as weakness, perspiration, hunger, nausea, anxiety and tremors can occur from one to two hours after a meal.

Anaemia

Anaemia may develop after gastric surgery, possibly from iron deficiency, caused by bleeding from recurrent ulcers, or by impaired iron absorption. Because of rapid stomach emptying, which prevents thorough mixing of food with gastric acid, iron is not converted to its absorbable ferrous form. Also, because of the surgery, iron may bypass the duodenum where 50 percent of iron absorption usually takes place.

Vitamin B12 or folate deficiency may also cause anaemia. There are two main reasons for the vitamin B12 deficiency — firstly, if the amount of gastric lining is reduced, intrinsic factor may not be produced in quantities adequate to allow for complete vitamin B12 absorption. Secondly, bacterial overgrowth, which can occur with this type of surgery, would compete with the body for absorption of vitamin B12. Often vitamin B12 injections are given prophylactically by the doctor.

Malabsorption

Following gastric surgery, steatorrhoea may be a problem. This occurs due to defective digestion. Because the food may bypass the duodenum, the secretion of two hormones, secretin and pancreozymin by the lining of the duodenum can be reduced. These two hormones stimulate the pancreas to secrete its enzymes and bicarbonate, and therefore there is little secreted when they are not present. Medications and small frequent meals are recommended to overcome this.

It is very common for patients who have had a gastrectomy to have vomiting and weight loss. A number of factors contribute to the development of weight loss post-gastrectomy, however even patients with a total gastrectomy are able to ingest a quantity of food greater than that required for maintenance of ideal body weight. The key is to eat frequent, small meals. It may be necessary to try nutritional supplements such as Ensure to increase calorie intake. Overeating relative to the size of what is left of the stomach can result in vomiting. It is difficult for post-gastrectomy patients to learn that they often cannot eat at one time the amount of food they were able to eat before the operation.

Dietary guidelines

  • Eat six small regular meals per day and chew foods slowly — this will prevent overloading the stomach. Patients who have had a total or almost total gastrectomy often have difficulty eating large amounts of food at one time.

  • Although not always practical, try resting or lying down for 15 minutes after a meal allowing food to remain in the stomach for longer, thus decreasing the movement of food from the stomach to the small intestine, preventing dumping syndrome.

  • It is important that you limit (not totally) simple (refined) carbohydrates like sweets, sugar and coldrinks, since they are digested quickly and can aggravate the dumping syndrome. Opt for complex (unrefined) carbohydrates instead.

  • Try take liquids between meals and not with meals — drink liquids 30 to 45 minutes before eating or one hour after eating, rather than with meals. This prevents the rapid movement of food through the gut and allows for adequate absorption of nutrients. This is only necessary if dumping is a problem, if not, then small amounts of liquids can be consumed at mealtimes. Also, avoid very hot or cold foods or liquids if they affect you.

  • Some specific foods will cause problems, for example certain gas-forming foods which you will need to assess yourself — simply avoid these foods if you know for sure that they affect you. If they do not affect you, there is no reason why you should avoid them! Examples of gas-forming foods include beans, brussel sprouts, onions, cabbage, cauliflower, corn, broccoli, peppers, radishes, soyabeans, apples, avocados, sweetmelon etc.

  • It might be wise to stay away from strong spices like curry, pepper etc. Again, individual tolerance is important here.

  • Eat a wide variety of foods in the diet to provide adequate nutrition and to prevent weight loss and malnutrition.

  • If weight loss is a continuing problem and it is difficult to eat all the food recommended, nutritional supplements like Ensure should be taken to help meet calorie and nutrient needs.

  • Pectin, the soluble fibre found in fruits and vegetables, may help slow down the absorption of food.

  • If steatorrhoea is a problem, reduce the fat content of the diet, which is healthy anyway.

  • Often, dairy products can cause bloating, abdominal pain and diarrhoea. If these symptoms are present, lactose-free milk products such as soya milk, etc. may be substituted. Try longlife milk, boiled skim milk or yoghurt - the lactose content is low in these foods. Eat calcium rich foods such as dark green leafy vegetables and soft boned fish like sardines. Calcium supplements may be necessary.

    Here is a basic guideline of all the food groups to help you with your meal plan:

    Milk and products
    Recommended
     As tolerated: buttermilk; low fat or skim milk;
    Low-fat plain or artificially sweetened yoghurt;
    Low-fat or fat-free cheese

    Avoid
    Full-cream milk;
    Ice cream; malted or chocolate milk;
    Sweetened custard and pudding;
    Sweetened, fruited, or frozen yoghurt;
    Milkshakes

    Vegetables
    Recommended
     All

    Avoid
     None (unless specific ones cause discomfort)

    Fruits
    Recommended
     Fresh fruit,
    fruit canned in natural juice,
    unsweetened fruit juice

    Avoid
     Dried fruits, canned fruits in syrup, sweetened juice

    Breads and Grains
    Recommended
     Wholewheat crackers
    Spaghetti,
    Brown breads and rolls
    Rice
    Unsweetened cereals and porridges

    Avoid
     Sugar-coated cereals
    Refined carbohydrates like white bread
    Doughnuts, pastries

    Meats, fish and poultry
    Recommended
     Eggs, seafood, beef, poultry, pork

    Avoid
     None

    Fats and Oils
    Recommended
     Margarine, oils, salad dressings (in small amounts)

    Avoid
     None

    Sweets and Desserts
    Recommended
     Artificial sweeteners
    Low-calorie jelly

    Avoid
     Cakes, pies, cookies, jellies, jams, high sugar deserts, sherbet

    Beverages
    Recommended
     Sugar-free beverages, water

    Avoid
     Regular soft drinks

    Keeping a food diary is a useful tool to help identify offending foods. You may also want to see a registered dietician who can develop an individualised meal plan for you, as well as provide you with ways to control any side effects and ensure that nutritional needs are being met.