Diagnosing and treating acute abdominal pain s/p gastric bypass.
A 60-year-old male presented to the emergency department with his wife via personal vehicle for acute onset of abdominal pain with associated nausea and non-bloody, non-bilious emesis that began just prior to arrival. The patient described the pain as severe, diffuse, yet sharp and stabbing. He stated that he was diaphoretic at the onset of pain and that the pain has been constant.
On further questioning, he admitted one day of constipation without any flatus. The pain was worse with any movement and immediately caused him to retch. He denied anything making his symptoms better, similar episodes in the past and did not try anything prior to presenting to the emergency department.
Past medical history was significant for hypertension, gastroesophageal reflux disease (on Protonix) and was status-post Roux-en-Y gastric bypass surgery three years prior at an outside hospital. He denied any surgical complications of his bypass surgery.
Vital signs demonstrated hypertension (192/78), hypothermia (34.4), heart rate of 58 and 98% saturation on RA. On physical exam, the patient was in acute distress secondary to pain and was noted to have a firm abdomen with diffuse, severe abdominal tenderness to palpation. He had guarding with deep palpation, decreased bowel sounds, and was noted to have a diastasis rectus. Additionally, he was felt to have peritonitis.
The patient was made NPO and started on IV fluids. He required multiple doses of narcotic pain medicine to achieve some relief. Lab work included a point-of-care lactate that was elevated at 9.1. The patient was started on broad-spectrum antibiotics (Vancomycin and Zosyn) at this time with a concern for sepsis. The rest of the lab work was unremarkable other than a mild leukocytosis (12,700/uL) and an anion gap of 21 (likely 2/2 lactic acidosis). An EKG had a poor baseline with a normal sinus rhythm without signs of overt ischemia.
A bedside FAST exam did not demonstrate any significant pericardial/cardiac pathophysiology. There was a small volume of free fluid in the abdomen, but the resident was unable to assess the abdominal aorta secondary to bowel gas/distension and patient discomfort.
A STAT abdominal CTA aortic dissection demonstrated a diffuse abnormal small bowel with transition in small bowel caliber in the region of the distal ileal loops, which were consistent with severe enteritis with probable element of distal small bowel obstruction (figure 1). There was no evidence of thoracic or abdominal aortic aneurysm or dissection.
Acute care surgery was consulted and agreed the patient needed to go urgently to the operating room (OR).
Upon opening of the abdomen, diffuse dusky small bowel was noted with four liters of serous fluid evacuated. The entirety of the small bowel was ischemic but not necrotic (figure 2).
The small bowel was then followed from the gastrojejunal anastomosis and BP limb and was noted to be volvulized and herniated through the mesenteric defect from the prior jejunojejunal anastomosis site. Next, the peritoneum over the mesentery was widened and the bowel reduced with good return of blood flow.
The jejuno-jejunal anastomosis site and approximately 50 cm of the small bowel still appeared ischemic, but not necrotic. However, the remainder of the small bowel appeared healthy and viable. Given these findings, the patient’s abdomen was temporarily closed for a second look laparotomy. On re-exploration 24 hours after the index procedure, the entirety of the small bowel and all anastomotic sites appeared healthy and viable. Repair of three mesenteric defects jejuno-jejunal, transverse mesocolon and Petersen’s space were performed. The abdomen was closed. The patient recovered well from surgery.
Small bowel obstructions (SBOs) secondary to internal hernia (figure 3) can occur at any time after a Roux-en-Y gastric bypass (RNYGB) with a lifetime incidence of approximately three to five percent, which is related to the initial surgical approach, technique of mesenteric closure (although no high-quality evidence is available) and weight loss leading to loss of mesenteric fat (figure 3).
Patient presentation can vary from mild, chronic abdominal pain, to bowel ischemia secondary to strangulated internal hernia or volvulus. Patients with a history of RNGYB presenting with SBO always warrant a surgical evaluation regardless of laboratory or radiologic findings. Clinical diagnosis is paramount as delayed diagnosis can lead to intestinal necrosis.
Brolin RE, Kella VN. Impact of complete mesenteric closure on small bowel obstruction and internal mesenteric hernia after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2013 Nov-Dec;9(6):850-4. doi: 10.1016/j.soard.2012.11.007. Epub 2013 Jan 17. PMID: 23415691.
Chowbey P, Baijal M, Kantharia NS, Khullar R, Sharma A, Soni V. Mesenteric Defect Closure Decreases the Incidence of Internal Hernias Following Laparoscopic Roux-En-Y Gastric Bypass: a Retrospective Cohort Study. Obes Surg. 2016 Sep;26(9):2029-2034. doi: 10.1007/s11695-016-2049-8. PMID: 26757920.
Among patients who did not undergo closure of any mesenteric defect (group A 2005-2009), 21/600 (3.5 %) developed IH, while 17/976 (1.7 %) patients who underwent mesenteric defect closure (group B 2009-2014) developed IH (p = 0.027).
Mesenteric defect closure in laparoscopic Roux en-Y Gastric Bypass: A Randomized controlled trial. Ulysses Rosas, BA, Shusmita Ahmed, MD, Natalia Leva, BA, Trit Garg, BA, Michael Russo, MD, John M Morton, MD, MPH. Stanford University School of Medicine.