Thanks to Dr. Brothers for putting together today’s morning report (which was presented on 4/2/2012)!
Here’s the case:
35 yo F history gastric bypass surgery 7 years ago presents with severe epigastric pain. Denies N/V/D. Has been constipated for past 2 weeks, hasn’t been taking her bowel regimen for past 7 months. No recent fevers. Exam showed a young woman in no acute distress, with mild pallor. She had significant epigastric tenderness to palpation, but abdomen was soft. +Mild distension, tympanic to percussion.
Clinical question: What are some possible ED presentations of complications related to gastric bypass surgery?
Continue reading below for discussion and the conclusion of the case. . .
Some of the late complications that can occur include stricture/stenosis, marginal ulcer, internal hernia, reflux, and nutritional complications. Patients presenting with stricture/stenosis typically present with inability to tolerate PO and/or dysphagia. They can be diagnosed with an UGI series and upper endoscopy. Management is endoscopic dilatation. Marginal ulcers can develop at the site of the anastomosis. Patients with marginal ulcers will present with epigastric abdominal pain and dyspepsia, and are typically diagnosed on endoscopy. Management would be acid suppression as with usual peptic ulcer patients. Patients with reflux will present with dyspepsia, new-onset asthma symptoms, or worsening of chronic respiratory symptoms. Diagnosis can be made endoscopically. These patients should have acid suppression therapy. Nutritional derangements include iron deficiency anemia, fat soluble vitamin deficiencies, B12 deficiency, and hypercalcemia. Patients with internal hernias present with intermittent, crampy abdominal pain, and can be diagnosed with a CT scan or an UGI series. Management would be per surgical consultation. This is a surgical emergency, as the patients can quickly develop bowel necrosis. The diagnosis can often be seen on UGI and expedite surgical management (vs CT, which can take hours to get, and may delay definitive treatment, which carries higher risk of poor outcome). For all patients, surgery should be consulted, preferably before imaging. The initial choice of imaging depends on the patient presentation and the surgeon. Beware that radiologists in hospitals that do not have a high volume of these cases may miss a diagnosis on a CT or UGI.
The above patient was admitted to the surgery service for severe abdominal pain secondary to constipation, as she had been off her bowel regimen for 7 months prior to arrival. She also was noted to have a large amount of stool throughout the colon on CT, including a large stool ball in the rectum. She was given enemas, lactulose, and milk of magnesia, and kept on a clear liquid diet until she passed gas and stools. At this point she improved significantly, and her diet was advanced. She was subsequently discharged after a 5 day admission. She was discharged on percocet and oxycontin for her chronic pain. She was additionally given milk of magnesia and dulcolax rx to be used if needed.
Takeaway points- Call surgery early, don’t wait for imaging. Upper GI will often make the diagnosis with much less radiation and time than CT, and for surgeons that see a lot of these, they will frequently request UGI series first.
Reference- Edwards ED, Jacob BP, Gagner M, Pomp A.Ann Emerg Med. 2006 Feb;47(2):160-6. Epub 2005 Aug 15.Presentation and management of common post-weight loss surgery problems in the emergency department.
Jay Khadpe MD
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Great case Liz (I think I had this one with you). I saw a lot of these patients in Syrcuse and if you go to a center where they do these procedures. They come in often and very frequently have something wrong. Treat them like a transplant patient. The surgeons often like to take ownership of these patients and have a very low threshold for admission and work-up.
There’s a review on this subject in Annals of EM. Kind of boring, but the reference is below.
Edwards ED, et al. Presentation and Management of Common Post–Weight
Loss Surgery Problems in the Emergency Department
[Ann Emerg Med. 2006;47:160-166.]