Maria Altieri, MD, Dana Telem, MD, Gerald Gracia, MD, Aurora Pryor, MD. SUNY Stony Brook.
Patients presenting with abdominal pain and/or emesis following Roux-en-Y gastric bypass (RYGB) must be urgently evaluated for internal hernia – a potentially life threatening condition which requires emergent surgical intervention. Evaluation can be challenging as no clinical or radiographic finding is reliably diagnostic. Diagnostic laparoscopy remains the gold standard for diagnosis. As the majority of bariatric surgery is performed in women of childbearing age, pregnancy complicates matters further. Abdominal pain as well as emesis is not uncommon in pregnancy and differentiating this from internal hernia can be difficult. Additionally, use of imaging such as CT scan may be limited secondary to concern for radiation exposure and diagnostic laparoscopy may also pose undo risk. We reviewed our institutional experience and our algorithmic approach to pregnant women with abdominal pain following RYGB.
Following IRB approval, 5 pregnant patients who presented acutely with abdominal pain or emesis following RYGB were identified from 2010-2013 and a retrospective chart review was performed. Data regarding clinical presentation, physical exam, laboratory values radiographic studies, intraoperative findings and clinical outcomes of both mother and fetus were collected and reviewed.
Patients’ age ranged from 22 to 34 years (mean 28.4). Gestational age ranged from 9 to 31 weeks (mean 19.2). Average BMI at time of presentation was 30.27kg/m2. Of the 5 patients, 4 presented with abdominal pain and one with intractable emesis. Management of the patient with intractable emesis consisted of plain radiograph, serial abdominal exams and 24-hours of observation. For the 4 patients who presented with abdominal pain, all underwent laparoscopy. 2 underwent CT scans preoperatively, with one concerning for internal hernia which was confirmed in OR. The remaining 2 patients were taken to the OR based on clinical suspicion alone. Intra-operatively, two patients were found to have obstruction from adhesions. The other two patients were found to have an internal hernia. One patient had ischemic bowel, which led to a open conversion and an emergent c-section (28 weeks gestational age). There were no postoperative complications or mortality for either fetus or mother. Average hospital stay was 3.6 days.
Pregnant women with history of Roux-en-Y gastric bypass who present with abdominal pain should be evaluated emergently for an internal hernia or obstruction. Based on our experience we have created an algorithm for pregnant post-bariatric patients (Figure 1). This algorithm may prevent delay in diagnosis.
Figure 1. Algorithm for assessing the pregnant post-bariatric patient.