A 34 year-old woman comes to the physician for nausea, vomiting, and early satiety over the last 2 weeks. The vomiting occurs mostly after eating, even though she consumes small portions. She underwent Roux-en-Y gastric bypass surgery for morbid obesity 3 months ago. Her post-operative course was uncomplicated. Prior to the surgery, she had acid reflux disease, type 2 diabetes mellitus, hypertension, and hyperlipidemia. The patient has lost 15.9 kg (35 lb) since the surgery. She currently takes omeprazole, a daily multivitamin, and calcium, iron, and vitamin B₁₂ supplements.
Vital signs are within normal limits. Physical examination shows well-healed surgical scars on the abdomen but is otherwise unremarkable.
Laboratory results are as follows:

Which of the following is the most likely diagnosis?

Question

A 34 year-old woman comes to the physician for nausea, vomiting, and early satiety over the last 2 weeks. The vomiting occurs mostly after eating, even though she consumes small portions. She underwent Roux-en-Y gastric bypass surgery for morbid obesity 3 months ago. Her post-operative course was uncomplicated. Prior to the surgery, she had acid reflux disease, type 2 diabetes mellitus, hypertension, and hyperlipidemia. The patient has lost 15.9 kg (35 lb) since the surgery. She currently takes omeprazole, a daily multivitamin, and calcium, iron, and vitamin B₁₂ supplements.
Vital signs are within normal limits. Physical examination shows well-healed surgical scars on the abdomen but is otherwise unremarkable.
Laboratory results are as follows:

Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's clinical presentation is suggestive of outlet obstruction, a complication of Roux-en-Y bypass (RYGB) surgery. Stomal stenosis at the gastro-jejunal anastomosis is a common complication that occurs in about 5%-20% of RYGB patients. Patients typically present (3-6 months after surgery) with obstructive symptoms such as nausea, vomiting, abdominal pain, gastroesophageal reflux, dysphagia, and eventual inability to tolerate oral intake. Diagnosis is made with endoscopy and the treatment is endoscopic balloon dilation (serial dilations often required). Roux-en-Y bypass Cholelithiasis is another frequent RYGB complication that occurs in about 40% of patients due to rapid weight loss contributing to gallstone formation. The incidence of cholelithiasis may be decreased by prophylactic administration of ursodeoxycholic acid for up to 6 months after surgery. Dumping syndrome occurs in about 50% of RYGB patients. Patients typically present with abdominal pain, nausea, hypotension (due to a rapid osmotic fluid shift from plasma into the bowel), and reflex tachycardia. This can be avoided by replacing simple carbohydrates with complex carbohydrates and high-fiber, protein-rich foods. (Choice A) Bulimia nervosa is characterized by binge eating (consuming a large amount of food in a short period of time) with induced vomiting and caloric restriction between bingeing episodes. Patients typically are excessively worried about their body shape and weight. (Choice B) Patients with eosinophilic esophagitis typically have dysphagia, centrally-located chest pain, food impaction ("food getting stuck"), refractory heartburn, and upper abdominal pain. There is often a strong association with allergic disorders such as asthma, food allergies, and atopic dermatitis. (Choice C) Gastroparesis typically presents with nausea, vomiting, bloating, and postprandial fullness over a period of weeks to months. Patients often have a long-standing history of diabetes mellitus with labile glucose control and other autonomic symptoms (eg, peripheral neuropathy). This patient's acute presentation of gastrointestinal symptoms is most suggestive of outlet obstruction from stomal stenosis. (Choice D) Schatzki rings typically cause solid food dysphagia and are often associated with hiatal hernias but not vomiting or early satiety. Educational objective: Common complications of bariatric gastric bypass surgery include stomal stenosis, dumping syndrome and cholelithiasis. Stomal stenosis at the gastro-jejunal anastomosis typically presents with nausea, vomiting, abdominal pain, and early satiety. Dumping syndrome causes abdominal pain, hypotension and reflex tachycardia. __________ References: Endoscopic management of complications after gastrointestinal weight loss surgery (http://www.ncbi.nlm.nih.gov/pubmed/23142331) Stenosis in gastric bypass: Endoscopic management (http://www.ncbi.nlm.nih.gov/pubmed/22816008)

A 34 Year-Old Woman Comes to the Physician for Nausea