A 45-year-old woman comes to the office due to reflux, nausea, and vomiting for the past 3 weeks. The patient has daily heartburn, regurgitation, and a sour taste in her mouth. She also has severe nocturnal reflux and has been sleeping in a recumbent chair. The patient has had postprandial, nonbloody, nonbilious emesis, initially with solid food but lately also with liquids. She has not had fevers, diaphoresis, dizziness, syncope, abdominal pain, diarrhea, or constipation. The patient underwent a laparoscopic Roux-en-Y gastric bypass 4 months ago and has since lost 20.5 kg (45.2 lb). Medical history includes morbid obesity, type II diabetes mellitus, and hypertension. She does not take aspirin or nonsteroidal anti-inflammatory medications and does not use tobacco, alcohol, or illicit drugs. Temperature is 37.5 C (99.5 F), blood pressure is 132/78 mm Hg, and pulse is 78/min without orthostatic changes. Physical examination shows well-healed surgical scars. There is mild epigastric tenderness without guarding or rebound tenderness. The remainder of the examination reveals no abnormalities. Which of the following is the best next step in management of this patient?

Question

A 45-year-old woman comes to the office due to reflux, nausea, and vomiting for the past 3 weeks.  The patient has daily heartburn, regurgitation, and a sour taste in her mouth.  She also has severe nocturnal reflux and has been sleeping in a recumbent chair.  The patient has had postprandial, nonbloody, nonbilious emesis, initially with solid food but lately also with liquids.  She has not had fevers, diaphoresis, dizziness, syncope, abdominal pain, diarrhea, or constipation.  The patient underwent a laparoscopic Roux-en-Y gastric bypass 4 months ago and has since lost 20.5 kg (45.2 lb).  Medical history includes morbid obesity, type II diabetes mellitus, and hypertension.  She does not take aspirin or nonsteroidal anti-inflammatory medications and does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.5 C (99.5 F), blood pressure is 132/78 mm Hg, and pulse is 78/min without orthostatic changes.  Physical examination shows well-healed surgical scars.  There is mild epigastric tenderness without guarding or rebound tenderness.  The remainder of the examination reveals no abnormalities.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d876_482c_bc81_13321cc5be0b_MD0003_00 This patient underwent a Roux-en-Y gastric bypass, which bypasses most of the stomach by creating a small gastric pouch, a gastrojejunal (GJ) anastomosis, and a jejunojejunal anastomosis. Weight loss results from restricting food consumption (smaller gastric pouch) and inducing malabsorption as nutrients can only be absorbed in the common limb (where food from the alimentary limb meets pancreatic enzymes/bile acids from the biliopancreatic limb). The procedure is associated with several postoperative complications. This patient likely has stomal (anastomotic) stenosis, caused by progressive narrowing of the GJ anastomosis that leads to obstruction of gastric pouch outflow. This complication usually occurs within the first year after surgery, likely due to local tissue ischemia and ulceration. Patients typically have progressive symptoms including nausea, postprandial vomiting, gastroesophageal reflux, and dysphagia, to the point of not tolerating liquids. Diagnosis requires visualization of the GJ anastomosis via esophagogastroduodenoscopy (EGD), during which balloon dilation can be performed to open the narrowing. Patients sometimes require surgical revision if balloon dilation fails. (Choice A) Rapid emptying of food, especially highly osmotically active simple carbohydrates (eg, corn syrup), from the gastric pouch can cause dumping syndrome due to abrupt transfer of fluid from the circulatory system into the intestines. In addition to abdominal pain, nausea, and diarrhea, patients typically have hypotension and tachycardia accompanied by diaphoresis, lightheadedness, or syncope. None of these symptoms are present in this patient. (Choice C) A gastric emptying scan is the test of choice for gastroparesis, which can present with postprandial pain, vomiting, and early satiety. However, recent bypass surgery renders this test inaccurate and raises suspicion for outlet obstruction that must be investigated with EGD. (Choice D) Right upper quadrant ultrasound is useful in diagnosing cholelithiasis, which is a common complication after Roux-en-Y, especially in the setting of rapid weight loss. However, severe reflux and regurgitation are not typical of symptomatic cholelithiasis. (Choice E) Marginal ulcers can occur at the GJ anastomosis and can present symptomatically like stomal stenosis. These ulcers can be treated with proton pump inhibitors, but their presence should first be confirmed by EGD; empiric therapy is not appropriate. Educational objective: Roux-en-Y gastric bypass induces weight loss by restricting food intake and promoting malabsorption. Stomal stenosis is a potential complication that results from a narrowing of the gastrojejunal anastomosis, leading to symptoms of nausea, postprandial vomiting, gastroesophageal reflux, and dysphagia. Esophagogastroduodenoscopy is used for both diagnosis and treatment. References: The role of endoscopy in the bariatric surgery patient. (http://www.ncbi.nlm.nih.gov/pubmed/26038784) Outcome of endoscopic balloon dilation of strictures after laparoscopic gastric bypass. (http://www.ncbi.nlm.nih.gov/pubmed/18347868)

A 45-Year-Old Woman Comes to the Office Due to Reflux