Left Arrow Right Arrow Down Arrow Up Arrow Left Arrow Right Arrow Down Arrow Up Arrow

Bariatric Examination, Assessment, and Management in the Emergency Department

For the patient with potential complications after bariatric surgery

Section Icon Begin with the patient’s surgical history
Who performed the surgery?
The bariatric surgeon who performed the procedure can provide useful information and guidance
If that person is not available, consult the covering bariatric surgeon
If no bariatric surgeon is available, consider consultation with or transfer to an MBSAQIP-Accredited Facility
What procedure was performed?
Where was the surgery performed?
Patients don’t always present to the hospital where the surgery was performed
Sometimes they present to hospitals that don’t have bariatric coverage
In these situations, consider communicating with the primary bariatric surgeon
Consider the need for consultation with or transfer to the primary facility or another MBSAQIP Facility
When was the surgery performed?
<30 days earlier
  • Common complications include bleeding, wound infection, leak, intra-abdominal abscess, stricture, and early obstruction
  • Also, venothrombotic events such as mesenteric VTE (DVT/PE/mesenteric thrombosis [portal vein, superior mesenteric vein]), trocar hernia, and nutritional concerns
>30 days earlier
  • Common complications include intra-abdominal abscess, obstruction, internal hernia, gallstones, marginal ulcer, marginal ulcer+perforation, marginal ulcer+bleeding, strictures, GERD, slippage, prolapse, erosion, and nutritional concerns
When did the symptoms begin?
Acute onset
  • <30 days after the procedure with severe abdominal complaints
    • Consider leak from SG or GB until proved otherwise
  • Intractable or bilious emesis after GB
    • Consider intestinal obstruction or internal hernia until proved otherwise
    • For patients with unresolved pain, consider consultation with a bariatric surgeon or surgical team for evaluation and/or follow-up plan before discharge
How was the surgery performed?
Laparoscopically
Open, which has a higher incidence of hernia and wound infection
Revision, which can have a higher incidence of leak
Section Icon Examine the patient
What are the vital signs?
Fever and tachycardia can be early signs of leak
Increased oxygen requirements?
  • Consider respiratory compensation of metabolic acidosis or sepsis
What are the physical findings?
Can help localize symptoms to the epigastrium, right upper or lower quadrant
Peritonitis is a late sign of leak and should trigger the protocol for an unstable abdominal condition
  • Pain out of proportion to examination findings?
    • Suspect ischemia:
      • Check lactate and trend if elevated
      • Consider portal vein or mesenteric thrombosis
      • Order CT (abdominal-pelvic) with IV contrast (portal venous phase) and modified oral prep
      • Make sure that the CT results report mentions flow/patency in portomesenteric system
Section Icon Assess the patient’s testing and treatment needs
Where is the pain or complaint?
Abdomen
If the patient has unstable vital signs or is rapidly deteriorating:
  • Assess the ABCs and start IV, oxygen, monitoring, and NS bolus
  • Consider lactic acid measurement and ABG analysis for acutely ill patients to identify metabolic acidosis
  • Consider early consultation with a bariatric surgeon for emergent surgical exploration, either laparoscopic or open
  • If no bariatric surgeon is available:
    • Consider early consultation with a general surgeon
    • Assess stability for transfer and consider consultation with or transfer to an MBSAQIP-Accredited Facility
If the patient has stable vital signs and examination:
  • Consider appendicitis, cholecystitis, diverticulitis, and other common general surgical and gynecologic conditions
  • Consider pregnancy
  • Order laboratory tests: CBC count with differential, chem 10, LFTs with amylase/lipase, consider lactate
  • Order diagnostic imaging studies:1,2
    • KUB/upright chest xray to evaluate for signs of SBO, free air, constipation, band positioning
    • CT (abdominal-pelvic) with IV contrast (portal venous phase) and modified oral prep (drink 1-2 cups of water-soluble contrast medium just before the CT; the standard waiting period is unnecessary and might delay diagnosis and treatment)
      • The most useful, versatile, and sensitive diagnostic imaging modality to evaluate post-bariatric surgery complications
      • Criteria: prior abdominal surgery and older than 18 years, presuming normal renal function
      • Of note: waiting for oral contrast material to reach the intestines can delay diagnosis and treatment; discuss this with the bariatric surgeon who will accept the patient in transfer
    • Ultrasonography for focal right upper quadrant pain
  • Evaluate for biliary disease
Respiratory system
Assess the airway
Consider difficult airway needs early
Order laboratory tests
  • CBC with differential, chem 10, LFTs with amylase/lipase plus ABG, add D-dimer to evaluate for PE
Order diagnostic imaging tests
  • CXR
  • Chest CTA to evaluate for PE
If the patient also has abdominal complaints, pursue the abdominal pathway.
  • Tachypnea and tachycardia can be signs of PE or leak
Digestive system
Consider thiamine deficiency in any patient who has a history of prolonged vomiting, poor PO intake, or new-onset neurologic symptoms such as neuropathy, and manage accordingly:
  • Administer IVF with NS bolus and 100 mg IV thiamine3
    • Avoid giving glucose-containing IV fluids before IV thiamine in patients suspected to have thiamine deficiency (to prevent Wernicke-Korsakoff syndrome)
    • Thiamine can be administered IV for suspected thiamine deficiency without waiting for laboratory test results
Section Icon Manage the patient’s condition
First Steps
In bariatric patients presenting with acute complaints, consider obtaining IV access with a large-bore IV
Dehydration can make establishing access more difficult, so consider using ultrasound guidance
Order laboratory tests at the time of IV access: CBC count with differential, chem 10, LFTs with amylase/lipase; consider lactate
Bleeding
SG
From staple line, spleen, greater omentum, or trocar sites <30 days
  • Obtain type and screen, trend HCTs
GB
Intra-abdominal from staple line
  • Mesentery or trocar sites <30 days
    • Obtain type and screen, trend HCTs
Intraluminal – hematemesis and/or melena
  • Anastomotic or gastrojejunal more common than jejunojejunostomy <30 days
  • Marginal ulcer >30 days
  • If the patient is stable and responding to resuscitation:
    • Consult a bariatric surgeon for possible admission for observation and serial HCT measurements
  • If the patient is unstable and not responding to resuscitation:
    • Follow an airway, access, massive transfusion protocol
    • Reversal considerations if patient is anticoagulated
    • Consult a bariatric surgeon for endoscopy and/or emergent exploration with endoscopy
Obstruction
SG
Presents with dysphagia, nausea, vomiting, and epigastric pain
  • Can be due to edema, stricture, dietary indiscretion, food impaction, dehydration
  • Less commonly can be a leak (within the first 6 weeks after surgery); mesenteric thrombosis can present with similar symptoms2
Start IVF resuscitation with NS, then give 100 mg IV thiamine3
Obtain UGI
  • If the flow of contrast material is normal, do a PO trial; if successful, discharge the patient with instructions for a liquid diet and follow-up with the bariatric surgeon
  • If the flow of contrast material is very slow, or if there is luminal narrowing or complete obstruction, consult a bariatric surgeon
    • If this finding is associated with leukocytosis, fever, or abdominal pain, follow the leak pathway
GB
If <30 days after surgery:
  • Presents as frothy or bilious emesis, food regurgitation, nausea, abdominal pain, and inability to tolerate diet
  • Can be due to food impaction at the gastrojejunostomy (from edema or stricture), dietary indiscretion, bowel obstruction at the level of the jejunojejunostomy, and (rarely) internal hernia, or intraluminal bleeding
  • Dehydration or portomesenteric thrombus can present with similar symptoms
  • Start IVF resuscitation with NS, then give thiamine 100 mg IV3
  • Order CT with IV contrast and modified oral prep
    • If the flow of contrast material is normal, do a PO trial; if successful, discharge the patient with instructions for a liquid diet and follow-up with the bariatric surgeon
    • If the flow of contrast material is abnormal, consult a bariatric surgeon
If >30 days after surgery:
  • Can be due to internal hernia, intussusception, food impaction, or adhesions4,5
    • Consider internal hernia until proved otherwise for any intractable or bilious emesis, often associated with postprandial colic type and left upper quadrant pain (untreated internal hernias can lead to massive bowel loss)Figure 1Figure 2
    • Food impaction can be at the level of the gastrojejunostomy due to stricture, or less commonly at the jejunojejunostomy
      • Consult a bariatric surgeon
    • Order CT with IV contrast and modified oral prep
      • If the patient has an associated SBO, request a bariatric surgery consultation for exploration
      • If the flow of contrast material is normal, do a PO trial; if successful and the pain resolves, discharge the patient with instructions for a liquid diet and follow-up with the bariatric surgeon
      • If the flow of contrast material is abnormal or equivocal, consult a bariatric surgeon
      • For patients with unresolved pain, consider consultation with a bariatric surgeon or surgical team for evaluation and/or follow-up plan before discharge
    • If the patient has intractable vomiting of food or bile and is >6 weeks post surgery:
      • Consider placement of a NGT to 35-40 cm or first black line to intermittent low wall suction, or,
      • Preferably, ask a bariatric team to place the NGT
LAGB
Presents with dysphagia, nausea, nonbilious vomiting, food regurgitation, and epigastric pain
If the patient recently underwent band adjustment, the most likely cause is edema/food impaction
  • Deflate the band with a Huber needle VideoStep-by-Step Instructions
  • Do a PO trial:
    • If successful, discharge the patient with instructions for a liquid diet and follow-up with the bariatric surgeon
    • If unsuccessful, obtain UGI to rule out other problems with the band and consult a bariatric surgeon
    • Food impaction might require endoscopic intervention
If patient did not recently undergo band adjustment, consider band prolapse or chronic pouch dilation6
  • Deflate the band with a Huber needle VideoStep-by-Step Instructions
  • Consider ordering an abdominal xray to identify prolapse (especially if there is a prior xray to compare orientation of the band); a normally positioned gastric band has an 8-o’clock to 2-o’clock orientation (around 38°); vertical (90°) or horizontal (180°) orientation of the band is suspicious for prolapse Figure 3Figure 4
  • Do a PO trial:
    • If successful and the patient has no abdominal pain or the pain resolves, discharge with instructions for a liquid diet and follow-up with the bariatric surgeon
    • If unsuccessful, order UGI to rule out band prolapse and consult a bariatric surgeon
  • If abdominal pain persists despite deflation, consider band prolapse causing ischemia or other abdominal pathology; the tubing of the band can cause SBO (rare)
  • Consider CT (abdominal-pelvic) with IV contrast and modified oral prep and bariatric consultation for possible exploration
Leak and Portomesenteric Thrombosis
Symptoms include feeling unwell, abdominal or shoulder pain, fever, tachycardia, leukocytosis7
SG
Majority of cases <30 days after surgery
Can occur >30 days after surgery, but rare
LAGB
Incidence is rare
Secondary to intraoperative gastric injury, erosion, gastric necrosis from obstruction
GB
Almost all anastomotic or staple line leaks occur <30 days after surgery
  • Gastrojejunostomy leak is far more common than jejunojejunostomy leak, which is more common than leak in the remnant stomach Figure 5Figure 6
Marginal ulcer perforation can occur >30 days after surgery
Jejunojejunostomy perforation is rare without secondary distal obstruction or iatrogenic missed injury
If the patient is stable:
  • CT scan with IV contrast and modified oral prep is preferred to UGI to evaluate for associated abscess or other pathology that could be missed
  • Intra-abdominal abscess should be assumed to be a contained leak until proved otherwise
If the patient is unstable or shows signs of rapid progression to sepsis:
Mesenteric thrombosis (portal vein/SMV) Figure 7Figure 8
  • Check lactate and trend if elevated
  • Initiate systemic anticoagulation in emergency department
  • Consult bariatric surgeon for evaluation

References

  1. Kothari SN. Bariatric surgery and postoperative imaging . Surg Clin North Am. 2011;91(1):155-172.
  2. Trenkner SW. Imaging of morbid obesity procedures and their complications . Abdom Imaging. 2009;34(3):335-344.
  3. Pardo-Aranda F, Perez-Romero N, Osorio J, et al. Wernicke's encephalopathy after sleeve gastrectomy: Literature review . Int J Surg Case Rep. 2016;20:92-95.
  4. Koppman JS, Li C, Gandsas A. Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass: a review of 9,527 patients . J Am Coll Surg. 2008;206(3):571-584.
  5. Freeman L, Brown WA, Korin A, et al. An approach to the assessment and management of the laparoscopic adjustable gastric band patient in the emergency department . Emerg Med Australas. 2011;23(2):186-194.
  6. Zundel N, Hernandez JD, Galvao Neto M, et al. Strictures after laparoscopic sleeve gastrectomy . Surg Laparosc Endosc Percutan Tech. 2010;20(3):154-158.
  7. Kim J, Azagury D, Eisenberg D, et al. American Society for Metabolic and Bariatric Surgery Clinical Issues Committee. ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management . Surg Obes Relat Dis. 2015;11(4):739-748.

Acknowledgments

Bariatric Examination, Assessment, and Management in the Emergency Department

For the patient with potential complications after bariatric surgery

A collaborative educational project of the American College of Emergency Physicians and the American Society for Metabolic and Bariatric Surgery

Contributors
Alan S. Miller, MD, MBA, FACEP, CPEJulie Kim, MD, FACS, FASMBSFady Moustarah, MD, MPH, FRCSPavlos Papasavas, MD, FACS, FASMBSAnn M. Rogers, MD, FACS, FASMBS

ACEP Staff
Marta FosterMargaret MontgomerySandy SchneiderSteven Morrissey

Publisher’s Notice

The American College of Emergency Physicians (ACEP) makes every effort to ensure that contributors to its educational resources are knowledgeable subject matter experts. Readers are nevertheless advised that the statements and opinions expressed in this resource are provided as the contributors’ recommendations at the time of publication and should not be construed as official College policy. ACEP recognizes the complexity of emergency medicine and makes no representation that this resource serves as an authoritative resource for the prevention, diagnosis, treatment, or intervention for any medical condition, nor should it be the basis for the definition of, or standard of care that should be practiced by all health care providers at any particular time or place. To the fullest extent permitted by law, and without limitation, ACEP expressly disclaims all liability for errors or omissions contained within this resource, and for damages of any kind or nature, arising out of use, reference to, reliance on, or performance of such information.

© Copyright 2018, American College of Emergency Physicians, Dallas, Texas. All rights reserved. Printed in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this resource may be reproduced or distributed in any form or by any means or stored in a database or retrieval system without prior written permission of the publisher.

Requests for permission should be sent here.

Figure 1

Internal hernia with small bowel obstruction

Mesenteric “swirl” sign with small bowel obstruction

Close

Figure 2

Internal hernia with small bowel obstruction

Mesenteric “swirl” sign with small bowel obstruction

Close

Figure 3

LAGB prolapse

Close

Figure 4

LAGB prolapse

Vertical orientation of band consistent with prolapse

Close

Figure 5

Gastrojejunostomy leak

GJ leak
Pouch

Blind limb
Proximal alimentary limb
Close

Figure 6

Jejunojejunostomy leak

Extraluminal contrast with gas

Close

Figure 7

Portal vein thrombosis

Thrombus in the portal vein

Close

Figure 8

Portal vein thrombosis

Thrombus in the portal vein

Close

Lap Band Adjustments

Close

Protocol for an unstable abdominal condition

If the patient has unstable vital signs or is rapidly deteriorating, please also read the "Abdomen" section here:

Path: ASSESS the patient’s testing and treatment needs / Abdomen / If the patient has unstable vital signs or is rapidly deteriorating:

Close

Protocol for an unstable abdominal condition

If the patient is unstable or shows signs of rapid progression to sepsis, please also read the "Abdomen" section here:

Path: ASSESS the patient’s testing and treatment needs / Abdomen / If the patient has unstable vital signs or is rapidly deteriorating:

Close

Step-by-Step Instructions for Deflating a Band With a Huber Needle

Scroll ↓
  1. Identify the port site: Location varies based on technique but is generally in the upper abdomen just below the largest laparoscopic incision site; if difficult to locate, ask the patient where it is or use plain radiography to identify the radio-opaque port
  2. Palpate the port: Feels like a chemotherapy or infusion port, consisting of a flat surface membrane (septum)
  3. Prep the skin using aseptic solution; a local anesthetic agent can be used, but it generally is not necessary and might make identification of the port more difficult
  4. Stabilize the sides of the port, then position a Huber needle connected to an empty syringe perpendicularly to the septum
  5. Feel resistance once the needle has passed through the septum and hits the plastic casing; fluid should be apparent within the syringe
  6. Pull back on the syringe to aspirate as much fluid as possible, then release the syringe while the needle is still in position and discard the fluid
  7. Repeat with an empty syringe if additional fluid is present and until all fluid is aspirated; there can be up to 11 mL of saline depending on the band model, as follows:
    • REALIZE Band-C, maximal fill volume 11 mL
    • REALIZE Band, maximal fill volume 9 mL
    • LAP-BAND AP Large (APL), maximal fill volume 4.5 mL
    • LAP-BAND AP Small (APS), maximal fill volume 4 mL
  8. Keep negative pressure on the syringe to prevent air from getting into the port system, then remove the needle and syringe
Close
24/7 LIVE CHAT