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Gastrointestinal Problems - Gastro-Oesophageal

Dr Jules Eden, dive medicine specialist and founder of e-med, answers divers' questions - as published in Sport Diver magazine:
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Q - I had weight loss surgery a few years ago. The procedure I had was called gastric bypass. Ironically I sold my dive gear to help pay privately for the procedure, thinking I'd never need it again. But having the surgery gave me a new lease of life and I have been thinking about getting back into the water. Is diving possible? Would there be any risks, or limits on my depth? All I'm interested in is shallow recreational dives in warm water, nothing extreme. Hope you can give me some good news.

A - I think I can. Gastric bypass surgery has been around for nearly 50 years, so surgeons are well aware of the possible complications of the procedure. The pleasant-sounding “dumping syndrome” is the most troublesome – cold sweats, butterflies, bloating and diarrhoea after eating (particularly whilst watching any form of reality TV). Small meals low in sugar are the order of the day (which is the whole point). On the whole results are good and weight loss sustained. A newer surgical approach is to wrap a band around the stomach, the size of which can be adjusted by injecting or removing saline through a port placed under the skin. This can be done via keyhole surgery (“laparoscopically”) and is hence commonly called a “lap band”. In Europe we are also blessed with the similar variant “Swedish adjustable gastric band”. Aren’t we lucky people? One charming complication of this procedure is Productive Burping, the regurgitation of swallowed food. Slower eating and more thorough mastication normally sort this out. Ascent from a dive can cause some acid reflux which might be an issue with either of these procedures, but this can usually be treated with antacids or similar drugs. Air trapping is unlikely as the gut is still “open” at either end for the important release of expanding gases. So assuming you have none of the above problems, go dive.

Q - I went on a Red Sea liveaboard a month ago and the first couple of days were fine, great in fact, but from day three, after each dive I started to notice slight bubbling/gurgling sounds in my chest. These got worse over the week, and I started getting burning pains as well. By the end I had to bail out of the last two dives as my chest was so sore. I felt sick too, and half the time couldn't sleep as lying down made it worse. I'm only 40 years old so I'm praying this doesn't mean the end of diving for me.

A - Don’t panic, this is actually quite a common complaint and thankfully it’s unlikely to terminate your diving career prematurely. These are the typical symptoms of gastro-oesophageal reflux disease (GORD), which are often exacerbated by diving. Think of your stomach as a bottle filled with acid, and your oesophagus (food pipe) the long neck of the bottle. Normally a handy little sphincter stops acid entering the oesophagus, but in some situations (for example lying down, or being horizontal in the water) the acid refluxes through it, up the long neck of the bottle, and causes your typical heartburn and nausea. Pretty unpleasant during a dive. The risk factors for GORD are numerous: certain foods (fatty or spicy stuff, chocolate, caffeine, citrus fruits), certain drugs (nicotine, alcohol, anti-inflammatories), obesity, advancing age and tight clothing are those most prevalent in the diving community. If any of these apply then address them. Luckily there are also plenty of medicines to help. Some coat the lining of the oesophagus, others stop the acid secretion from the stomach, and sometimes a course of “triple therapy” will eradicate pesky bacteria that can contribute to the symptoms. So before your next dive ask your GP to give your gullet the once-over.

Q - Your advice would be appreciated. I have just started my Divemaster training and am planning to DM in the UK. Anyhow, in 2004 I had a gastric band fitted - which has been very successful having now lost about 9 stone. Will I be able to dive?

A - Firstly, congratulations on that huge initial weight loss, impressive indeed. For those in the dark, gastric banding is one of a big range of “anti-obesity” procedures performed these days. Notable luminaries who have undergone the operation include Sharon Osbourne and Anne Diamond. It involves putting an inflatable device around the top part of the stomach via keyhole surgery. This “band” creates a small pouch above it, which therefore fills quickly and produces a “full” sensation, while also slowing down the passage of food through the rest of the stomach. In theory this means the wearer feels full more easily, eats less, and loses weight. The tightness of the band can be varied by injecting or withdrawing saline from it, until a happy medium is found. Very clever stuff.

There are one or two issues with bands and diving however. There is a particular side effect charmingly referred to as “PB’ing” – Productive Burping – which can result in regurgitation of food from the upper pouch. Similarly, reflux of acid stomach contents can be a problem, especially if they come up into the mouth – a misplaced retch or cough could lead to a dropped regulator and inhalation of water. But in the absence of these hitches and as long as there is no gas trapping, there is no reason you shouldn’t dive afterwards.

Q - I am 63 years of age, have been diving since 1994, am qualified to Advanced Open Water with PADI and have completed about 80 recreational dives always in warm climates, e.g. Red Sea, Great Barrier Reef, British Virgin Islands, etc. I was diagnosed some time ago with Peripheral Neuropathy which was mild then but has increased in severity over the years. Luckily I only have problems with my toes/feet, e.g. numbness, pins and needles, burning sensations, occasional cramps, all the usual PN stuff. I take no medication for this but take Lansoprazole (15mg) for Barrett's Oesophagus. Otherwise I am reasonablyfit for my age and take 30 mins of fairly testing cross-country machine training 5 times a week.

Do you perceive any problems related to the PN with me continuing scuba diving on a strictly recreational basis?

A - Not really with the peripheral neuropathy. This illness where nerves in the periphery stop doing what they are supposed to do can be a real pain, as I am sure you know. But the deal with diving is that as long as you have sufficient strength there to fin, haul out a buddy or get back on the boat then that should be OK. It is worth seeing a dive doc to get passed as fit, as well as getting a neurological mapping of your deficit. Numbness and pins and needles are classic bends symptoms, so you need to have a good idea of what's going on baseline, as it could save 5 hours in a chamber if you had a problematic ascent and an over zealous doctor.

The Barrett's though is an issue. This is caused by hyperacidity in the oesophagus, and needs the antacids to prevent pain and burning in this tube. As long as it does not affect your diving, causing reflux or pain when you are horizontal, then cool. If you are a gastric belchy sort of diver then there could be a risk of an acid vomit on a dive, so get that all checked out when the doc is stroking your tootsies with cotton wool before jabbing a pin into big toe.

Q - Dear Dr Eden I recently had a little incident while diving in Chepstow in that while at 25m I began to cough and retch small amounts of blood. This unfortunately led to my aspirating some of this blood, making breathing difficult. I ascended slowly and got to the surface safely but feeling very weak and required assistance exiting. Due to a slightly over enthusiastic response I wound up spending a few days in hospital until my 02 sats had picked up a bit. Now, if I am to continue as a DM or progress further I will require an HSE medical. ( What are my chances of passing this, with this problem?) It has been established that I have got a small recurrence of these varicies but the gastro lot at St George's don't intend to treat them this time as they regard them as fairly small . So I am rather left without a definite answer as to whether I may dive as before or with limitations or not at all. I would greatly appreciate any advice you may offer as to my next step to getting back in the water.

A - This is pretty serious stuff. Varicies, or oesophageal varicies as they are known in long hand, are blood filled swellings in the oesophagus caused by problem with the vasculature in that area. The issue here is that they can bleed at any point, sometimes disastrously. In your case they have done that and you inhaled the blood at depth. Lucky to be alive, and I guess this is a testament to your "sang froid" underwater.

Now imagine if you were DM'ing and it happened again. You would be putting not only your, but your other divers' lives at risk. So it's no diving for you I am afraid.

What the hospital considers small and not worth operating on though needs another look. If diving is your life and you want to continue, then you need to find out why you have varicies and if they could fix them with a guarantee you will not bleed again. If they can do this, then you may well be able to dive and DM in the future.

Q - I have only just started diving seriously and intend to dive on a more regular basis. Since starting diving I have noticed that every time I finish a dive I get heart burn and have to have Zantac 75 on hand to get rid of it before my next dive. I am wondering if this is just a minor problem or whether it is something that could possibly affect my diving future.

A - Heartburn or reflux oesophagitis is one of those highlighted things on the PADI med dec form. The danger here is, that if it is uncontrolled, good old gastric acid can spill up into your oesophagus on a dive, into your throat and either come out as a vomit through your reg, or more lethally, be re-inhaled. This will cause a spasm in your breathing tubes, laryngospasm, it's known as. If you get this underwater, your next sight will not be a little wrass but the Grim Reaper himself.

The reason you may get this diving is because of your body position and your gear. A horizontal dive position with a tight BCD and weight belt can squeeze your abdomen forcing up the acid.

So if that is the issue, then consider an integrated weight belt or a larger BCD.

However, as you are getting it so regularly I suggest you see your GP and consider a course of omeprazole to really knock the problem on the head. This is an antacid that is better at long term prevention of gastric acid problems. If this does not help then it's a gastroscopy for you. That's a 50 cm flexible tube they shove down your oesophagus to have a look at what lies within.

Not a lot of fun but better than having a chunder at 30 metres.

Q - Having been diving for the last few years and visiting a few places I still have one problem. That is, when I return to the boat after a dive I sick [sic!!] and throw up, but this is only when I try to get on the boat. I am ok if my head is below the water but this is very embarrassing. This normally only happens on boat dives. Could you advise if there is anything I can do about this?

A - I have given this a lot of thought. Consulted some of the wisest sages that have learnt the arts of Hippocrates. And all we can come up with is a guess.
If all is OK on the dive. Up from your safety stop. With your head bobbing above the water. But then you paint the deck as you pull yourself up, the only thing it could be is an increase in intra-abdominal pressure brought on by the exertion of hauling yourself up kitted still.

On your next boat dive here are my tips.

Don’t eat for at least 2 hours before you dive so your stomach is empty.

Remove your weight belt before getting onto the boat.

Remove your BC and tank and let the boat meister haul them up for you.

This should work but if not then I suggest you either get the same guy to gently lift you onto the vessel, or tape a sick bag onto your face so you have your hands free to hold a mop and bucket of water if it blows.

Q - I'm a 39-year young (ok, sensitive with age) new diver ... started September 2001, who has become thoroughly hooked on the sport (no help required with that!). I'm working towards my Advanced Open Water cert as well as completing the Enriched Air course and have a holiday booked to the Red Sea with my dive club pals. What I'd like to know is whether my SAGB* (fitted Sept 2000) is likely to be affected by diving, especially as I intended to work towards deeper dives.
Since having the SAGB I'm 68k (BMI 23) having lost 47k. None of my dive club pals knew me then and it is something I'm reluctant to bring up with the instructor: vanity as well as the fact the procedure is not that common in the UK (I went to Lyon for it) and they probably won't have the information anyway. So, is the band likely to cause me any problems as I expand my diving skills?

* Swedish Adjustable Gastric Band

A - Thanks for explaining the acronym as to tell the truth I have never heard of it before. Likewise anything Swedish and adjustable could easily be assumed to affect the bedroom rather than the stomach. But I think I'm right in assuming it's a band that is put around the stomach to squeeze it smaller so you need less food to feel full. Hence the weight loss. And as you lose weight I assume it can be either relaxed or tightened to help you further.

So what about diving with it?

As it is not air filled that's fine. The only real issue is does if cause any reflux of gastric contents back up the oesophagus. If it does because it's too tight or you are trying to get too much food in you for your new stomach width then that is a real problem. Acid regurgitation with a reg in your mouth can be fatal. On dry land you can retch merrily away to get spit the acid out, or even rush to the pharmacy to get the Gaviscon. However down with the fish there is a chance that you can inhale the acid, go into a paroxysm of coughing. Reg comes out. You drown.

Only you know if you get any reflux. If you do, don't dive until the band is off. If you really don't then I hope you enjoy your trip to Egypt. Mind you, with some of the local delicacies I've seen out there you don't need an operation to put you of eating.

(other dive medical questions)


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