Bloating after Nissen Fundoplication

Bloating after Nissen Fundoplication

Mike from Cypress sent us this question: “Is it common to have bloating only at night preventing me from getting a good night sleep after Nissen fundoplication?”

Dear Mike,

Bloating and excessive burping are very common acid reflux symptoms. Stage 3 and 4 acid reflux patients tend to constantly and unconsciously swallow saliva and air to quench acid reflux. This results in air accumulation in the stomach leading to gastric distention and the sensation of bloating. Concomitantly, air in the stomach escapes back into the esophagus due to weak lower esophageal sphincter and through the mouth leading to excessive burping.

When a Nissen fundoplication is performed for stage 3 and stage 4 acid reflux, at Houston Heartburn and Reflux Center, less than 10% of patients develop what we call gas bloat syndrome. Patients feel bloated for approximately 3 weeks after surgery because they continue to swallow air even after acid reflux has stopped. It takes 3 weeks to get over the habit of swallowing air. 3 weeks after Nissen fundoplication patients report bloating resolution.

A minority of patients continue to have bloating 3 weeks post-surgery. Most of them report increased flatulence too. Excessive gas production by colon bacteria causes both bloating and increased flatulence. Constipation, irritable bowel syndrome, (IBS), and dietary related indigestion (FODMAPS, gluten) are common causes of bloating and flatulence independent of acid reflux disease. I have successfully treated patients with these conditions using gas absorbing medicine like Simethicone also known as Gas-X and probiotics. For patients with constipation, supplementation with a daily non-psyllium fiber helps alleviate bloating. An osmotic laxative may be added for non-responders. In some cases, dietary modification like gluten-free diet is all what is needed to eliminate bloating and flatulence.

Of note, we know that proton pump inhibitors negatively affect colon health and microbiota. Acid reflux patients who have been maintained on medications like Nexium and Dexilant for many years prior to Nissen fundoplication, have a damaged colon microbiome. Nissen Fundoplication gives acid reflux patients the opportunity to stop proton pump inhibitors. The resumption of normal stomach acid production restores a healthy colon microbiome. A balanced gut microbiome is essential for normal digestion free of bloating and flatulence.

Finally, a poorly performed Nissen fundoplication may be associated with persistent bloating among other symptoms. Obviously, the solution in this case is to redo the fundoplication. A properly performed Nissen fundoplication improves quality of life. A properly performed Nissen fundoplication for the right acid reflux patient effectively resolves acid reflux symptoms without increasing the risk of maldigestion, bloating and discomfort.