Clinical and laboratory study of postvagotomy diarrhoea

Abstract

SUMMARY Thirty-two patients with diarrhoea, on average four years following truncal vagotomy and drainage, were studied. A comparison was made with 24 patients without postvagotomy diarrhoea. The incidence of bacterial colonization of the upper small intestine was no different in the two groups, though patients with a gastroenterostomy had a significantly higher incidence than those with a pyloroplasty. There was a higher incidence of 'anaerobic colonization' in patients with diarrhoea, but statistical significance was not reached.Colonization was associated with significantly lower levels of gastric acid secretion. Though 13 patients with diarrhoea had an abnormal faecal fat excretion, no correlation could be found between this and the severity of the diarrhoea or bacterial colonization, either with an anaerobic or a coliform type flora.In patients with diarrhoea, no small intestinal mucosal abnormality was detected, the mean haematological and serum biochemistry values were within normal limits, and the body weight was similar to that before operation.Two patients with diarrhoea had abnormal haematological values five years following vagotomy and gastroenterostomy in association with 'anaerobic colonization' of the upper small intestine. As the incidence of haematological abnormalities after gastric surgery increases with time, colonized patients might merit particularly close clinical observation.

The role of IgA in the prevention of bacterial colonization of the jejunum in the vagotomized subject

“…On the other hand, when all three putative defence mechanisms were disturbed, significant jejunal colonization occurred (group 6). This observation both confirms and explains the findings of others (Dellipiani and Girdwood, 1967;Tinker et al, 1971;Browning et al, 1974) that when intestinal IgA secretion is normal, post-vagotomy diarrhoea (as in group 3) need not necessarily be associated with significant jejunal colonization, and that some other aetiology such as coeliac disease (Hedberg et al, 1966), lactose intolerance (Welsh et al, 1966) or disturbed gastric emptying (McKelvey, 1970;Colmer et al, 1973) must be sought. Furthermore, our findings provide an explanation as to why jejunal colonization is seldom found in immune-deficient individuals (McCarthy et al, 1965).…”

“…The jejunal aspirate was diluted tenfold, plated immediately and incubated for 4 days under both aerobic and anaerobic conditions. The protocol employed was identical to that of Browning et al (1974). Organisms were identified as pharyngeal, colonic or anaerobic species and their numbers expressed as log,, organisms per millilitre of aspirate.…”

“…In the Merseyside survey into the incidence and aetiology of severe post-vagotomy diarrhoea (McLoughlin et al, 1976) 6 of the 14 patients who developed this complication were found to have primary IgA deficiency and significant jejunal bacterial colonization. It has been reported, however, that there is no significant difference in the incidence of jejunal colonization between those patients who have and those who have not developed diarrhoea following truncal vagotomy (Browning et al, 1974). The present study was designed to examine the contribution of each putative defence mechanism in the prevention of significant bacterial colonization of the vagotomized jejunum.…”

Guidelines for the investigation of chronic diarrhoea, 2nd edition

“…These include those with intestinal dysmotility syndromes associated with systemic disease (for example, diabetes, scleroderma, intestinal pseudoobstruction), and those with anatomical disorders of prior surgery (for example, terminal ileal resection) or strictures of the small bowel. Gastric surgery and, in particular, that involving a blind loop is associated with a high prevalence of SBBO: up to 50% of patients with gastrojejunostomy and vagotomy compared with 5% of those with vagotomy and pyloroplasty, 159 although the clinical significance of this finding is unclear. 160 161 Other structural disorders of the small bowel such as jejunal diverticulosis are also associated with SBBO.…”