A 42-year-old man comes to the emergency department due to epigastric abdominal pain. The pain started acutely this morning and is constant and unrelated to eating. The patient describes it as severe and worsening in intensity over time. He also has had chills, rigors, and shortness of breath but has no chest pain, vomiting, melena, diarrhea, or hematochezia. The patient was discharged from the hospital 3 days ago after a Roux-en-Y gastric bypass surgery with no intraoperative complications. Medical history is otherwise significant for morbid obesity and type II diabetes mellitus. He does not use tobacco or alcohol. Temperature is 38.4 C (101.1 F), blood pressure is 110/78 mm Hg, pulse is 125/min, and respirations are 21/min. Oxygen saturation is 96% on room air. Physical examination shows no scleral icterus and moist mucous membranes. Heart sounds are normal with no murmurs, rubs, or gallops. The lungs are clear to auscultation bilaterally. The abdomen is tender to palpation in the epigastrium and is moderately distended. There is no rebound tenderness or guarding. The surgical incision shows mild surrounding erythema with no bleeding or drainage. Laboratory studies are as follows: Which of the following is the best next step in management of this patient?

Question

A 42-year-old man comes to the emergency department due to epigastric abdominal pain.  The pain started acutely this morning and is constant and unrelated to eating.  The patient describes it as severe and worsening in intensity over time.  He also has had chills, rigors, and shortness of breath but has no chest pain, vomiting, melena, diarrhea, or hematochezia.  The patient was discharged from the hospital 3 days ago after a Roux-en-Y gastric bypass surgery with no intraoperative complications.  Medical history is otherwise significant for morbid obesity and type II diabetes mellitus.  He does not use tobacco or alcohol.  Temperature is 38.4 C (101.1 F), blood pressure is 110/78 mm Hg, pulse is 125/min, and respirations are 21/min.  Oxygen saturation is 96% on room air.  Physical examination shows no scleral icterus and moist mucous membranes.  Heart sounds are normal with no murmurs, rubs, or gallops.  The lungs are clear to auscultation bilaterally.  The abdomen is tender to palpation in the epigastrium and is moderately distended.  There is no rebound tenderness or guarding.  The surgical incision shows mild surrounding erythema with no bleeding or drainage.  Laboratory studies are as follows:  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient's presentation is concerning for a postbariatric surgery anastomotic leak. Following Roux-en-Y gastric bypass, this complication can occur due to breakdown of either the gastrojejunal or jejunojejunal surgical anastomosis, leading to leakage of gastrointestinal contents into the peritoneum. The leak usually develops within the first week after surgery and can include fever, abdominal pain, tachypnea, and tachycardia. Heart rate >120/min has been shown to be the most sensitive predictor of postoperative anastomotic leak. Roux-en-Y gastric bypass Patients with a suspected anastomotic leak should undergo an oral contrast-enhanced abdominal CT scan or upper gastrointestinal series, followed by urgent surgical repair if a leak is demonstrated. Because an anastomotic leak is associated with high rates of morbidity and mortality, urgent surgery is still recommended if the index of suspicion is high enough, even if imaging is nondiagnostic. (Choice B) Pulmonary embolism is common after surgery, and CT angiogram of the chest is the diagnostic test of choice. Although a pulmonary embolism can present with fever, tachypnea, and tachycardia, severe abdominal pain is unlikely. (Choice C) An esophagogastroduodenoscopy (EGD) can evaluate for a marginal ulcer (ulceration at the gastrojejunal anastomosis), which usually presents several months to years after surgery with nausea, abdominal pain, or evidence of bleeding (eg, melena, anemia). However, EGD is contraindicated if an anastomotic leak is suspected as it can worsen the leak and cause frank perforation. (Choice D) A HIDA scan is used to diagnose cholecystitis by demonstrating cystic duct obstruction. Although gastric bypass patients are at increased risk for developing gallstones months to years after surgery, gallstone disease is unlikely in the immediate postoperative period. Right upper quadrant ultrasound is typically the initial test to evaluate for gallstone disease. (Choice E) Reassurance and symptomatic (eg, pain) management is not appropriate because an unrecognized anastomotic leak will likely progress to peritonitis and overwhelming sepsis. (Choice F) Clostridioides difficile colitis typically presents with leukocytosis and severe, watery diarrhea in recently hospitalized patients or those exposed to antibiotics; the absence of diarrhea makes the diagnosis very unlikely. Educational objective: Anastomotic leak is a serious postoperative complication that can present with fever, abdominal pain, tachypnea, and tachycardia, usually within the first week after bariatric surgery. The diagnosis is best confirmed by oral contrast-enhanced imaging (either abdominal CT scan or upper gastrointestinal series), and treatment requires urgent surgical repair. References: Clinical predictors of leak after laparoscopic Roux-en-Y gastric bypass for morbid obesity. (http://www.ncbi.nlm.nih.gov/pubmed/12618940)

A 42-Year-Old Man Comes to the Emergency Department Due to Epigastric