What do you notice on her CXR?
Our patient has a lapband. This device was used in the past for weight loss surgery but is no longer favored because of band migration and erosion. This is an important part of the history to obtain because of the complications associated with weight loss surgery.
A brief synopsis of the evolution of weight loss surgery follows. These surgeries are intended for those with a BMI of 30 or greater.
1. Roux-en-Y gastric bypass involves a combination of stomach reduction and connection of the small stomach to a portion of the intestine. Food bypasses the stomach and part of the small bowel. This is good for weight loss both from early satiety and dumping but if the pt presents with:
Vomiting-- be aware the anastomosis with the stomach can stenose causing the equivalent of an esophageal food impaction. Internal hernias, and edema of the anastomosis can result as well as anastomotic ulcers.
An acute abdomen—consider an anastomotic leak
RUQ pain—consider gallstones; 15% of Roux-en-Y patients get them
2. Lap band- is much less invasive but done less often now because of migration of the band and erosion of the esophagus. This occurs in about 2% of patients. These patients present with vomiting.
3. Gastric sleeve- removes 80% of the stomach. Consider a ruptured staple line if the pt presents with a GI bleed.
4. Duodenal switch- leaves the pyloris intact and is associated with fewer anastomotic ulcers. It is more effective at curing diabetes. These patients are more likely to develop malnutrition and thiamine/vitamin deficiencies.
5. Intragastric balloons- are having a resurgence but the Orbera Intragastric balloon and ReShape integrated dual balloon system have recently been implicated in 12 deaths including perforation of the stomach, perforation of the esophagus , pancreatitis and spontaneous hyperinflation of the balloon.
Our patient had esophagitis with thickening of the distal esophagus found on CT. The CT was done to ro rib fractures since she would be predisposed to malnutrition.. She was referred back to her bariatric surgeon. Remember, any patient with a gastric bypass can present with Wernicke’s.
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Nelson DW, Blair KS, Martin MJ. Analysis of obesity-related outcomes and bariatric failure rates with the duodenal switch vs gastric bypass for morbid obesity. Arc Surg 2012;147:847.
Le Roux CW, Welbourn R, Weling M, et al. Gut hormones as mediators of appetite and weight loss after Roux-en-Y gastric bypass. Ann Surg 2007;246:780.