I had my follow up with Dr. Frech. Oh boy. It was a bit
overwhelming and I still feel like I am in the same boat.
I am just going to copy the office note from Dr. Frech so I don’t
have to re-write the information from an hour long visit!
(I took out most personal information)
Noel understandably is frustrated about her up/down course as we
previously shared optimism at her last clinic visit that her condition was
seemingly improving following her most recent exploratory laparoscopy with
adhesionlysis. Unfortunately, her symptoms have slowly worsened since her
feeding tube was removed following her last clinic visit and she had become
more reliant on oral nutrition. She has, in fact, lost 7 pounds since I last
saw her and only consuming 900-1000kcal daily as she has pain with eating.
I am perplexed by Noel's
persistent symptoms and share in her frustration with seemingly worsening
symptoms since last seen. Her symptoms seemed to improve significantly with her
most recent adhesionolysis surgery suggesting at least component of adhesions
contributing to her symptoms. She really hasn't ever become accustomed to
reduced size of gastric remnant following initial surgery and hasn't been able
to eat normally for over a year now. I think a component of her poor tolerance
to eating is due to reduced gastric compliance from not eating normally for so
long…
I have recommended the following:
1. Continue linaclotide 290mcg daily. Consider adding Miralax 1-4
capfuls daily if persistent constipation.
2. Noel previously did not tolerate metoclopramide and unable to obtain
domperidone. I am concerned about starting erythromycin as prokinetic, which
may be a potential therapeutic option for her though already on multiple other
drugs that prolong QT. She is going to see her cardiologist within next week.
She has underlying Wolf Parkinson White and I'm really not sure about adding
erythromycin as another potential QT prolonging agent. Will hold on doing this
for now given already taking Zofran… and tramadol. My hope would be that by
slowly increasing her diet and thereby increasing her gastric compliance, she
will then be able to tolerate higher volumes of food though she hasn't not been
able to push herself to do thus far due to postprandial pain and nausea…
3. Begin bedtime promethazine to help control nocturnal nausea.
Continue…zofran during daytime with hopes this allow her to better tolerate
increased PO and improve gastric remnant compliance.
4. Begin monthly B12 injections given fatigue and "low
normal" B12 levels. Hold on adding iron though iron slowly dropping likely
related to bypass anatomy and poor diet.
5. Continue Ensure or Boost at least 3 times daily. She is adamant
about not having nasoenteric feeding tube replaced thus will have to try best
to optimize oral nutrition.
I asked her to contact my office in the interim if she continues to
lose weight and I asked her to have her cardiologist send repeat ECG results
(prior QTc 12/2014 ECG 432ms).
It was a long visit and a lot of information. But I am so
grateful that Dr. Frech always takes his time to go over everything with me and
works so hard to figure out some solution. I think at this point, things are
going to just be trial and error until we can resolve some symptoms. I really
am not super concerned about my weight anymore. I just need to still step up my
eating and push myself and hopefully if I can eat semi-normal meals than the
other symptoms will resolve themselves. The pain issue is a whole other issue
and I guess we will cross that bridge when it becomes unbearable again.
These gave me a good laugh!
