Dr. Sara Nelson: Today’s case is that of a 5-year-old boy who presented to the Emergency Department (ED) with complaint of bilateral leg pain for 10 days. He described the pain as involving his knees through his ankles. The pain was sharp and occurred intermittently throughout the day. The pain was worse in the afternoons and with running and jumping. The boy’s parents had noticed that he was walking with a slow, shuffling gate. There was no history of trauma, leg swelling, or joint instability. According to his parents, the patient was a healthy boy with normal growth and development. He had never been hospitalized, took no medications, and was allergic only to peanuts. Immunizations were up to date. There was no relevant family history. Review of systems was notable for 6 weeks of fatigue and a fever on the day before presentation. He saw his pediatrician, who noted some bilateral hip tenderness. Plain radiographs of the hips and pelvis were obtained. These were normal and he was referred to the ED.

On initial examination, vitals signs were: temperature 37.3°C, pulse 122 beats/min, blood pressure 114/49 mm Hg, respiratory rate 22 breaths/min, and oxygen saturation 100% on room air. He was a well-nourished boy in no distress. Examination of the head revealed reactive round symmetric pupils, anicteric sclerae, and moist mucous membranes. The oropharynx was clear without erythema or exudates. The neck was supple with slightly enlarged cervical lymph nodes. The lungs were clear to auscultation bilaterally. Heart sounds were regular, with no murmurs. The abdomen was soft, non-tender, and non-distended. The liver edge was palpable 2 cm below the right costal margin. There was no splenomegaly or other masses. The scrotum and testes were normal and without masses. There was inguinal and axillary lymphadenopathy bilaterally. There was no swelling, erythema, or point tenderness of the extremities. Joint examination was normal with full passive range of motion of the hips, knees, and ankles. There was no joint laxity. The back was non-tender. Neurological examination was notable for a slow, somewhat shuffling gait but was otherwise normal.

Dr. David Brown: Are there any thoughts as to the initial differential diagnosis

Dr. Eric Nadel: We have a child with leg pain and gait disturbance and a question of fever. The differential diagnosis at this point is rather broad. Infectious causes of leg pain include septic arthritis, osteomyelitis, myositis, and discitis of the intervetebral discs. Septic arthritis is a serious diagnosis that cannot be missed as it can cause rapid joint destruction. History of fever, non-weight bearing, erythrocyte sedimentation rate > 40 mm/h, and a serum white blood cell count of > 12,000 cells per cubic millimeter are strong clinical indicators of septic arthritis of the hip (1). Inflammatory causes of limp and leg pain include transient synovitis, juvenile rheumatoid arthritis, and lupus. Neuromuscular causes of leg pain include muscular dystrophy, peripheral neuro-pathy, and reflex sympathetic dystrophy. Musculoskeletal injury is, of course, a common cause of leg pain; often there may be no history of overt trauma. Stress fractures can occur with repetitive loading activities in children and occur most often in the tibia, fibula, pars intrarticularis, and femur (2). Toddler’s fractures occur in the distal third of the tibia in children between 9 and 36 months of age and occur after trivial injuries (3). And, of course, child abuse should always be a consideration when dealing with any pediatric injury.

Dr. Daniel Pallin: Another category of leg pain and limp is bony deformity. Bilateral developmental dysplasia of the hip can present as a lordotic, swaying limp in older children, whereas unilateral developmental dysplasia of the hip is often picked up during infant screening or when a toddler starts to walk (4). Slipped capital femoral epiphysis, in which the femoral epiphysis slips posteriorly, occurs most often in obese children in early adolescence (5). Legg-Calvé-Perthes is an idiopathic avascular necrosis of the hip and usually presents as a painless limp in children 2 to 12 years old (6). Another common cause of leg pain in children, especially active adolescents, is Osgood-Schlatter disease, which is an over-use syndrome that leads to osteochondritis and apophysitis of the tibial tuberosity at the insertion of the patellar tendon (7).

Dr. Nelson: We considered all of these categories of leg pain when evaluating this patient. The history and physical examination were notable for subacute onset of symptoms, normal musculoskeletal examination, and associated symptoms of fever and fatigue. Given these symptoms, tumor and malignancy were also part of our initial differential diagnosis. Osteoid sarcoma is a benign tumor of children and adolescents that can present with a limp and with leg pain, especially at night. The femur is the most commonly affected bone (8). The two most common malignant bone tumors in children are osteogenic sarcoma and Ewing’s sarcoma (9). Common sites for these tumors are the distal femur, proximal tibia, and humerus. Ewing’s sarcoma can also affect the axial skeleton (10). Finally, 20–30% of children with acute leukemia may present with bone and joint pain (11). The pain often involves the long bones and is due to leukemic infiltration of the periosteum. The presence of generalized lymphadenopathy in our patient made us particularly concerned about this diagnosis.

Dr. Ben White: How did you proceed with the work-up

Dr. Nelson: Given these diagnostic considerations, our initial work-up in the ED included a complete blood count with differential, serum electrolytes and liver function tests, urinalysis, chest radiograph, and cultures of the blood. The results of the complete blood count (CBC) sharply defined the differential diagnosis, as the white blood cell count was 6.29 K/mm³ with 10% neutrophils and 31% lymphoblasts. The hematocrit was 27.7% and the platelet count was 104 K/mm³. Results of the other laboratory testing were as follows: sodium 133 mEq/L, potassium 4.5 mEq/L, chloride 98 mEq/L, bicarbonate 23 mEq/L, BUN 21 mEq/L, creatinine 0.5 mEq/L, and glucose 100 mEq/L. Calcium was 10.2 mEq/L, magnesium was 2.2 mEq/L, and phosphate 5.5 mEq/L. Liver function tests revealed AST 130 mEq/L, ALT 99 mEq/L, alkaline phosphatase 201 mEq/L, total bilirubin 0.3 mEq/L, uric acid 3.7 mEq/L, and lactate dehydrogenase (LDH) 1297 mEq/L. The urinalysis was normal. The chest radiograph revealed no infiltrates or masses.

Dr. Nadel: The CBC is highly suggestive of acute leukemia, given the anemia, thrombocytopenia, borderline neutropenia, and blast predominance in the white cell differential. What additional evaluation was performed in the ED

Dr. Nelson: A peripheral blood smear was prepared and oncology was consulted. During the ED course, the patient developed a fever to 39.0°C and was empirically started on cefepime for his relative neutropenia (640 cells/mm³). He was admitted to the pediatric oncology service with the presumptive diagnosis of acute lymphocytic leukemia.

Dr. J. Tobias Nagurney: The leukemias are the most common malignant neoplasm in children, accounting for about 30% of all malignancies in children < 15 years of age (12). It is important to consider this diagnosis in the ED, especially when children present with persistent, non-specific symptoms. Acute lymphocytic leukemia (ALL), which is a disorder of T- or B-cell progenitor cells (or lymphoblasts), is about five times more common than acute myeloid leukemia, which is a disorder of myeloblasts (13). The presentation of ALL in children is varied. Common symptoms include musculoskeletal pain, lymphadenopathy, headache, mediastinal mass (seen most commonly in adolescent males with T-cell ALL), testicular enlargement, fever, bleeding, fatigue and, of course, peripheral blood abnormalities.

Dr. Jennifer Millen: What are the peripheral blood abnormalities that are seen in ALL and how is the definitive diagnosis made

Dr. Nelson: Acute leukemia leads to bone marrow failure. As a result, anemia or thrombocytopenia will be seen in most patients (14). The white blood cell count can vary, with about half of patients having initial leukocyte counts of < 10,000/mm³ and 20% having a leukocyte count of > 50,000/mm³ (15). Lymphocytes may be initially reported as “atypical,” but further examination of the peripheral smear will reveal > 25% lymphoblasts (14). Bone marrow aspirate or biopsy will confirm the diagnosis of ALL and should be performed whenever the peripheral blood suggests the possibility of leukemia.

Dr. Ruth Lamm: Were you concerned about tumor lysis syndrome in your patient

Dr. Nelson: Tumor lysis syndrome is a metabolic derangement that is caused by the rapid release of intracellular contents when leukemic or cancerous cells are destroyed. Typically, tumor lysis syndrome occurs 1–5 days after the initiation of chemotherapy, but can occur before starting treatment (16). As should be done in every new diagnosis of leukemia, we ordered blood tests from the ED to screen for tumor lysis syndrome. In particular, we evaluated for hyperuricemia, hyperphosphatemia, hypocalcemia, and hyperkalemia. We screened for acute renal failure that can be caused by the deposition of uric acid crystals in the renal tubules. In our patient, each of these tests was normal and so we felt tumor lysis syndrome was unlikely. The LDH was elevated at 1297 mEq/L. Uric acid and LDH levels correlate with the total tumor burden and the risk of developing tumor lysis syndrome (16). To prevent tumor lysis syndrome, patients should be given two times maintenance intravenous fluids without potassium. In addition, sodium bicarbonate can be administered to alkalanize the urine (pH 7.5–8), which enhances phosphate and uric acid secretion. Allopurinol also can be given to prevent or correct hypocalcemia.

Dr. Alison Lozner: What was this patient’s hospital course

Dr. Nelson: Flow cytometry testing was consistent with pre-B cell ALL. On the next hospital day, a bone marrow biopsy confirmed the diagnosis. Subsequent evaluation included cerebrospinal fluid cytology, ophthalmology examination, and echocardiogram, all of which were normal. The patient was started on induction chemotherapy and a tumor lysis protocol was initiated with intravenous fluids, urine alkanalization, and allopurinol. He was treated with cefepime and vancomycin for continued fevers although his blood and urine cultures remained negative throughout his hospital stay. He received multiple blood transfusions for his anemia. The patient was discharged on hospital day number 25. A repeat bone marrow biopsy on day number 32 of the chemotherapy protocol confirmed remission; consolidation therapy was subsequently begun. The patient returned to school after being out for 3 months and, according to his most recent oncology clinic notes, is still in remission and doing well.

Dr. Brown: This case raises some interesting and important points. First, as was stated earlier, the differential diagnosis of leg pain and limp in a child is very broad and should always include malignancy, especially when the child has persistent and unexplained symptoms. The second point is that leukemia is the most common form of malignancy in children and early diagnosis can greatly improve outcome. The initial cancer and tumor lysis work-up should start in the ED. The ED evaluation should include: a CBC with differential; tumor lysis syndrome laboratory tests including uric acid, LDH, basic metabolic panel, phosphate and calcium; liver function tests, coagulation studies, fibrinogen and D-dimer to assess for disseminated intravascular coagulation; urinalysis, urine cultures, and blood cultures if there is evidence of infection; baseline viral titers to look for other causes of atypical lymphocytes; and a chest radiograph to look for a mediastinal mass (most common in T-cell ALL). A testicular ultrasound is indicated if the testes are enlarged and a lumbar puncture should be performed before the initiation of treatment to assess for central nervous system involvement, but these tests can generally be done on the in-patient service. ED treatment should be aimed at tumor lysis syndrome or infection if either is suspected.

References

1 M.S. Kocher, D. Zurakowski and J.R. Kasser, Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm, J Bone Joint Surg Am 81 (1999), pp. 1662–1670.

2 A. Hulkko and S. Orava, Stress fractures in athletes, Int J Sports Med 8 (1987), pp. 221–226. View Record in Scopus | Cited By in Scopus (91)

3 M. Tenenbein, M.H. Reed and G.B. Black, The toddler’s fracture revisited, Am J Emerg Med 8 (1990), pp. 208–211. Abstract | Full Text + Links | PDF (551 K) | View Record in Scopus | Cited By in Scopus (10)

4 C. Dezateux and K. Rosendahl, Developmental dysplasia of the hip, Lancet 369 (2007), pp. 1541–1552. Abstract | Full Text + Links | PDF (211 K) | View Record in Scopus | Cited By in Scopus (1)

5 R.T. Loder, The demographics of slipped capital femoral epiphysis An international multicenter study, Clin Orthop Relat Res 322 (1996), pp. 8–27. View Record in Scopus | Cited By in Scopus (69)

6 G. Thompson, The hip. In: R.E. Behrman, R.M. Kleigman and H.B. Jenson, Editors, Nelson textbook of pediatrics (17^th edn.), Saunders, Philadelphia (2004), pp. 2273–2280.

7 G. Thompson, The knee. In: R.E. Behrman, R.M. Kleigman and H.B. Jenson, Editors, Nelson textbook of pediatrics (17^th edn.), Saunders, Philadelphia (2004), pp. 2271–2273.

8 Wheeless′ textbook of orthopaedics. Available at: http://www.wheelessonline.com/. Accessed August 23, 2007.

9 J.G. Gurney, A.R. Swensen and M. Bulterys, Malignant bone tumors. In: L.A.G. Ries, M.A. Smith and J.G. Gurney et al., Editors, Cancer incidence and survival among children and adolescents: United States SEER Program 1975–1995 (NIH pub. no. 99–4649), National Cancer Institute, SEER Program, Bethesda, MD (1999), pp. 99–110.

10 K.A. Pierz, R.B. Womer and J.P. Dormans, Pediatric bone tumors: osteosarcoma, Ewing’s sarcoma, and chondrosarcoma associated with multiple hereditary osteochondromatosis, J Pediatr Orthop 21 (2001), pp. 412–418. View Record in Scopus | Cited By in Scopus (14)

11 R.J. Rogalsky, G.B. Black and M.H. Reed, Orthopaedic manifestations of leukemia in children, J Bone Joint Surg Am 68 (1986), pp. 494–501. View Record in Scopus | Cited By in Scopus (48)

12 S.R. Rheingold and B.J. Lange, Oncologic emergencies. In: G.R. Fleisher, S. Ludwig and F.M. Henretig, Editors, Textbook of pediatric emergency medicine (5^th edn.), Lippincott Williams & Wilkins, Philadelphia (2006), pp. 1240–1274.

13 SEER cancer statistic review, 1973–1999, National Cancer Institute, Bethesda, MD (2000), p. 467.

14 D.G. Tubergen and A. Bleyer, The leukemias. In: R.E. Behrman, R.M. Kleigman and H.B. Jenson, Editors, Nelson textbook of pediatrics (17^th edn.), Saunders, Philadelphia (2004), pp. 1694–1698.

15 J.F. Margolin, C.P. Steuber and D.G. Poplack, Acute lymphoblastic leukemia. In: P.A. Pizzo and D.G. Poplack, Editors, Principles and practice of pediatric oncology (5^th edn.), Williams & Wilkins, Philadelphia (2006) R2 OnLine Library. Available at: http://www.R2Library.com/marc_frame.aspxResourceID=212. Accessed November 16, 2007..

16 R. Gucalp and J. Dutcher, Oncologic emergencies. In: D.L. Kasper, E. Braunwald and A.S. Fauci et al., Editors, Harrison’s principles of internal medicine (16^th edn.), McGraw-Hill, New York (2005) Harrison’s Online. Available at: http://www.accessmedicine.com/. Accessed August 23, 2007..

Keywords: perirectal abscess; penile discharge; urethritis; scrotal pain; rectal examination

Article Outline

Introduction

Case Report

Discussion

Conclusion

References

Introduction

Anorectal abscesses are a common cause of patient presentation to the Emergency Department (ED). The most frequently reported symptom of this abscess is rectal pain; however, this entity’s wide spectrum of symptomatology frequently leads to misdiagnosis ([1], [2] and [3]). We report a case of a patient with an ischiorectal abscess in whom penile discharge was the presenting symptom.

Case Report

A 42-year-old man with no significant past medical history presented to our ED with a chief complaint of scrotal pain and swelling for 3 days. One week before arrival, he developed penile discharge. He was seen at a different institution where he was diagnosed, on clinical grounds, with gonococcal urethritis. At that time, he was treated with “a shot” and discharged on oral ciprofloxacin.

Three days before arrival, he developed scrotal pain and swelling associated with dysuria and back pain, for which he presented to our ED. He denied fever, abdominal pain, nausea, vomiting, diarrhea, and constipation. The patient attributed his symptoms to a hernia as he works in construction and performs heavy lifting. He denied any significant past medical or surgical history. His only medication was ciprofloxacin, and he had no allergies to medications. Although his social history was significant for unprotected intercourse with women, he denied practicing anal-penetrative or anal-receptive intercourse. He smoked cigarettes daily and consumed alcohol occasionally.

On physical examination, he was in mild distress due to pain. The oral temperature was 37.7°C (99.8°F), heart rate was 136 beats/min, respiratory rate was 20 breaths/min, blood pressure was 127/65 mm Hg, and oxygen saturation was 98% on room air. The genitourinary examination revealed a symmetrically swollen and diffusely tender scrotum with bilateral inguinal lymphadenopathy. No penile discharge was present. A fluctuant, tender left perirectal mass was identified on digital examination. The prostate was normal and stool was negative for occult blood. The remainder of the physical examination was unremarkable.

Based on physical examination findings, the diagnosis of perirectal abscess was investigated. The patient was initially treated with intravenous gatifloxacin and metronidazole and given morphine for pain. Laboratory values revealed a white blood cell count of 35,800/mm³ (79% neutrophils, 2% bands); the remainder of the complete blood count was normal. Serum electrolytes and renal and liver functions were also within normal limits. Urinalysis was remarkable for 2+ protein, 2+ hemoglobin, 50–100 red blood cells, absent nitrite and leukocyte esterase. A computed tomography (CT) scan of the abdomen and pelvis with oral and intravenous contrast revealed a left ischiorectal abscess, 4.5 × 4 cm, with extension into the left corpus cavernosum (Figure 1). The patient was taken to the operating room.

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Figure 1. Computed tomography (CT) scan of abdomen and pelvis. Arrows indicate ischiorectal abscess with extension into the left corpus cavernosum.

 

Under general anesthesia, an ischiorectal abscess was identified adjacent to the bladder, anteroinferior to the prostate. The abscess was incised without complications, and approximately 50 mL of purulent material was drained. Abscess material was sent for culture.

The patient was continued on antibiotics (intravenous ampicillin/sulbactam and oral doxycycline). He improved clinically and was discharged in good condition on post-operative day 4. Culture of the abscess fluid grew Prevotella bivia, latex-negative Staphylococcus, and Streptococcus constellatus. Urine culture was negative. Cytology was negative for malignancy.

Discussion

Although no culture was obtained at initial presentation, we believe it is unlikely that the patient had both gonorrhea and a non-gonococcal ischiorectal abscess simultaneously. Although Neisseria gonorrhea has been reported to cause ischiorectal abscess, cultures from our patient’s abscess grew Prevotella bivia, latex-negative Staphylococcus, and Streptococcus constellatus ([4] and [5]). These organisms represent normal bowel flora, and are typical of previously described perirectal abscesses (6). Cultures were negative for gonorrhea and chlamydia. The penile discharge was likely a manifestation of abscess extension into the corpus cavernosum. Such extension has been previously described, resulting in dysuria or urinary retention (7). However, to the best of our knowledge, penile discharge has never been reported as a presentation of anorectal abscess. We do not know the physical examination findings at the time of initial presentation as the patient was seen at a different institution. Possibly, the abscess was too small to identify on rectal examination or a rectal examination was not performed at initial presentation.

The differential diagnosis of penile discharge includes sexually transmitted infections, including gonorrhea, chlamydia, trichomonas, and other causes of non-gonococcal urethritis. It also has been reported to occur in herpes, syphilis, urethral stricture, and urethral carcinoma. We believe that perirectal abscess should be considered in the differential of penile discharge. Therefore, we recommend a digital rectal examination that can give information as to its presence, as well as involvement of the prostate gland.

Genitourinary involvement of anorectal abscesses has been described. Dysuria and urgency may occur due to involvement of the base of the bladder ([2] and [3]). Urinary retention is reported as a presenting complaint of anorectal abscess in a series of five patients (7). These patients had extension of pus to the urethral sphincter and surrounding the membranous urethra, resulting in urethral edema (7). Urethral edema likely resulted in the microscopic hematuria seen in our patient.

Misdiagnosis, a frequent phenomenon in patients with anorectal abscess, often leads to increased complications ([1] and [3]). The most common misdiagnosis is hemorrhoids. Other misdiagnoses include anal fissure, fistula-in-ano, and constipation. Misdiagnosis leads to delays in treatment, and increased complications including fever, prolonged drainage, and the need for repeat incision and drainage. We report penile discharge as yet another manifestation of anorectal abscess. The digital rectal examination, too often omitted by clinicians, proved pivotal in identifying the correct diagnosis in our patient. Due to the potential for increased morbidity and even mortality when this entity is misdiagnosed, an aggressive search for anorectal abscess must be performed. In patients who present with penile discharge, we suggest that a thorough digital rectal examination be performed seeking the presence of mass or fluctuance. It is well documented that patients are often reluctant to report the presence of rectal pain to physicians, especially in the setting of penile or vaginal discharge (3). Patients may feel that their discharge and rectal pain are part of the same disease process that will improve with whatever medication the doctor prescribes. In patients with penile discharge with negative cultures, failure to improve on antibiotics, or development of rectal pain, a CT scan with oral and intravenous contrast may be indicated to exclude deep anorectal abscess.

Conclusion

We report a case of ischiorectal abscess with extension into the corpus cavernosum presenting as penile discharge. We suggest considering this disease entity and performing a digital rectal examination in patients presenting with penile discharge to exclude anorectal abscess.

References

1 P.J. Kovalcik, R.L. Peniston and G.H. Cross, Anorectal abscess, Surg Gynecol Obstet 149 (1979), pp. 884–886. View Record in Scopus | Cited By in Scopus (4)

2 P.H. Hanley, Anorectal supralevator abscess-fistula in ano, Surg Gynecol Obstet 148 (1979), pp. 899–904. View Record in Scopus | Cited By in Scopus (2)

3 R.H. Marcus, R.J. Stine and M.A. Cohen, Perirectal abscess, Ann Emerg Med 25 (1995), pp. 597–603. Abstract | Full Text + Links | PDF (955 K) | View Record in Scopus | Cited By in Scopus (8)

4 Y. El-Dhuwaib and B.J. Ammori, Perianal abscess due to Neisseria Gonorrhoeae: an unusual case in the post-antibiotic era, Eur J Clin Microbiol Infect Dis 22 (2003), pp. 422–423. View Record in Scopus | Cited By in Scopus (1)

5 T. Read, A. Mijch and L. Ostergaard, Gonococcal perianal abscess, Sex Transm Infect 78 (2002), p. 389. View Record in Scopus | Cited By in Scopus (2)

6 I. Brook and E.H. Frazier, The aerobic and anaerobic bacteriology of perirectal abscesses, J Clin Microbiol 35 (1997), pp. 2974–2976. View Record in Scopus | Cited By in Scopus (24)

7 P. Cassell, Urinary retention associated with infection in the ischiorectal and supralevator spaces, Br J Surg 56 (1969), pp. 918–920

Article Outline

Introduction

Surgical Strategies for the Treatment of Obesity

Bariatric Surgery Procedures

Restrictive Procedures

Vertical banded gastroplasty

Gastric banding

Malabsorptive Procedures

Gastric bypass

Biliopancreatic diversion

Laparoscopic approaches

Complications of Bariatric Surgery

Surgical Complications

Pulmonary Complications

Nutritional Complications

Hepatobiliary Complications

Gastrointestinal Complications

Neurological Complications

Conclusion

References

Introduction

Obesity has become one of the most prevalent conditions in the United States. More than 50% of adults meet the clinical definition of being overweight or obese, and 5% are considered severely obese (1). Obese individuals are at elevated risk for a number of conditions that can increase mortality, including Type II diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, asthma, cardiovascular disease, gallbladder disease, and obstetric complications ([2] and [3]). As a result, obesity is one of the most common causes of preventable mortality in the United States (4). Unfortunately, medical treatment and dietary and lifestyle changes have proven to be of minimal benefit to those who are morbidly obese ([1] and [5]). However, surgical treatment of obesity provides morbidly obese individuals with sustained weight loss and significant reductions in the diseases associated with excess weight (6).

There has been a dynamic growth in the number of bariatric surgical procedures for obesity. From 1990 to 2000, the national annual rate of bariatric surgery increased nearly six-fold, from 2.4 to 14.1 per 100,000 adults (7). Recently, less invasive techniques, specifically laparoscopic bariatric surgery, have become commonplace in the treatment of morbid obesity. This review will discuss the most common surgical procedures for the treatment of obesity, the complications that can arise post-operatively, and the assessment and management of the bariatric surgery patient who presents to the Emergency Department (ED).

Surgical Strategies for the Treatment of Obesity

In 2000, the National Institutes of Health published an evidence-based guideline for the surgical management of obesity. Patients are eligible for bariatric surgery if they have failed attempts at non-surgical management and have a body mass index, defined as weight in kilograms divided by height in meters squared, > 35 with a physiologically related co-morbidity, such as type II diabetes, or > 40 years of age without a co-morbidity (1).

There are two main strategies for surgically induced weight loss—gastric restriction and intestinal malabsorption. Procedures involving gastric restriction cause early satiety by creating a small gastric pouch, which limits the volume of solid food that can be ingested in a given period of time. Satiety is also prolonged by creation of a small gastric outlet. Restrictive procedures involve gastroplasty and gastric banding. It was determined early in the development of these procedures that the gastric outlet needed to be reinforced to prevent dilatation. Therefore, a prosthetic material is often used to reinforce the gastric outlet. Both the pouch and the outlet need to be small enough to restrict intake and increase satiety, but large enough to prevent obstruction. Special adjustable band systems have been developed to allow for fine adjustments of the gastric outlet diameter. Despite the fact that significant dietary compliance is required with restrictive operations, the benefits of these procedures include the technical simplicity with no staples, anastamoses, or bypasses of the intestinal tract.

Malabsorptive procedures used today include the biliopancreatic diversion with or without duodenal switch and the distal gastric bypass. Malabsorptive surgeries involve some degree of gastric volume reduction but, more importantly, rely on the bypass of various lengths of the small intestine. Functionally, this creates what has been described as a “controlled short-gut syndrome.” Benefits of these procedures include a greater sustained weight loss that is less dependent on the patient’s dietary compliance (8).

Bariatric Surgery Procedures

Restrictive Procedures

Vertical banded gastroplasty

Vertical banded gastroplasty is a restrictive procedure that involves creating a small (30–50 mL), vertically oriented pouch with a narrow gastric outlet (Figure 1). The pouch is created by stapling the front wall of the stomach to the back below the gastroesophageal junction. The distal end of the newly created pouch is constricted with either a 1-cm diameter polypropylene band or a 1-cm silastic ring. These procedures have not been found to be as effective as other bariatric procedures in achieving long-term reduction in excess weight; only 25–45% of patients maintain their weight loss at 10 year follow-up ([9] and [10]).

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Figure 1. Vertical banded gastroplasty. A vertical pouch is created by stapling the front of the stomach to the back wall, below the esophagogastric junction. The end of the newly created gastric pouch is constricted with either a 1-cm diameter polypropylene band or a 1-cm silastic ring (vertical ring-banded gastroplasty). Reprinted with permission from Medscape General Medicine 6(2), 2004. http://www.medscape.com/viewarticle/471952 © 2004 Medscape.

 

Gastric banding

Gastric banding is a purely restrictive procedure that involves placing a silastic band below the gastroesophageal junction to restrict oral intake. This simple procedure does not involve surgically entering the gastrointestinal tract; therefore, operative risk and complication rates are reduced (11). Recently, a newer gastric banding technique involving an adjustable band has been approved for use in the United States (Figure 2). This technique involves laparoscopically placing an adjustable band around the upper stomach. This band is connected to a port is placed subcutaneously that can be accessed to inflate or deflate the band. By altering the amount of fluid in the band, the circumference of the band changes, thus altering the diameter of the outlet. This technique is the most popular bariatric surgery performed outside of the United States (12). Although long-term results have been favorable in Europe, this surgery has not demonstrated similar success in the United States ([13], [14] and [15]).

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Figure 2. Adjustable laparoscopic banding. A band is laparoscopically placed around the upper stomach to create a restrictive pouch. The balloon in the band is connected to a port that is placed subcutaneously and can be accessed to inflate or deflate the balloon, consequently changing the size of the band circumference. Reprinted with permission from Medscape General Medicine 6(2), 2004. http://www.medscape.com/viewarticle/471952 © 2004 Medscape.

 

Malabsorptive Procedures

Gastric bypass

Roux-en-Y gastric bypass involves both restrictive and malabsorptive components and has become the most common bariatric surgery performed in the United States (Figure 3). This procedure is estimated to be performed in the United States approximately 70,000 times per year, 70% of the total gastric bypass surgeries performed domestically (16). The diversionary component is the Roux limb, which bypasses the distal stomach, duodenum, and upper jejunum, and contributes to weight loss by causing malabsorption of calories and inducing a dumping syndrome. There are multiple variations in this procedure, but generally, a 15–50-mL gastric pouch is created with a 75–150-cm Roux-limb connected as an enteroenterostomy to the jejunum, 30–50 cm distal to the ligament of Treitz.

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Figure 3. Roux-en-Y gastric bypass surgery. A small pouch is created by either stapling or transecting the stomach. The pouch is then connected to and empties into the Roux limb of the jejunum, which is approximately 50–100 cm in length. Reprinted with permission from Medscape General Medicine 6(2), 2004. http://www.medscape.com/viewarticle/471952 © 2004 Medscape.

 

Biliopancreatic diversion

Biliopancreatic diversion is a two-component procedure: a limited gastrectomy and the creation of a long-limb Roux-en-Y anastomosis with a short, 50-cm alimentary channel (Figure 4A). The short channel is created by transecting the small intestine approximately 250 cm from the ileocecal valve and attaching the distal end to the gastric pouch. The proximal end is then joined near the ileocecal valve. This procedure leaves no defunctionalized small intestine. The biliopancreatic diversion can lead to significant weight loss through a decrease in oral intake and induction of significant malabsorption of fat by diverting bile and pancreatic secretions. Successful weight loss has been reported above 65–75% of excess body weight at 18 years post-surgery ([17] and [18]).

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Figure 4. (A) Biliopancreatic diversion. A limited gastrectomy is created, and the transected ileum is anastomosed to the gastric pouch. (B) Biliopancreatic diversion with duodenal switch. A sleeve gastrectomy is created to maintain the pylorus and avoid anastomotic complications. Similar to classic biliopancreatic diversion, the transected, distal small bowel is connected to the stomach via a small part of the first potion of the duodenum. Reprinted with permission from Medscape General Medicine 6(2), 2004. http://www.medscape.com/viewarticle/471952 © 2004 Medscape.

 

Biliopancreatic diversion with duodenal switch is a promising alternative to a standard biliopancreatic diversion (Figure 4B). This procedure involves a sleeve gastrectomy involving 70–80% of the greater curvature of the stomach, maintenance of the pylorus and a small part of the duodenum, and the construction of a Roux-en-Y duodenoenterostomy. The benefit of this adaptation is that the maintenance of the pylorus and duodenal system reduces the post-operative malabsporption complications, such as stomal ulceration.

Laparoscopic approaches

Laparoscopic bariatric surgery procedures have been emerging since the mid-1990s. Advantages over open procedures include reduced peri-operative morbidity, mostly wound related, and shorter recovery times ([19] and [20]). Laparoscopic techniques have additional challenges in morbidly obese patients, such as the greater distance through the abdominal wall, and hand-assisted laparoscopic techniques have been developed (21). The laparoscopic Roux-en-Y gastric bypass procedure has been described as one of the most technically challenging laparoscopic procedures to date (22).

Complications of Bariatric Surgery

Outcomes after bariatric surgery have dramatically improved over the last two decades. Hospital stays are more commonly 3–4 days as opposed to 9–10 days in the past (23). During the 1980s, one review found that 9% of patients had peri- and post-operative respiratory complications, 4% had anastamotic leaks, and 6% required repeat surgical intervention (24). Today, perioperative mortality of bariatric surgery is less than 1% ([25] and [26]).

Surgical Complications

There are a number of surgical complications of bariatric procedures that can present to the ED (Table 1). The most common cause of death after bariatric surgery is peritonitis from an anastomotic breakdown. This is typically an early complication, usually diagnosed within 10 days after surgery. The incidence of post-operative leak after Roux-en-Y gastric bypass ranges from 1–6% (27). Specifically, this has been noted to occur in 1.2% of open cases and 3% of laparoscopic cases (28). The classic peritoneal signs are not always present post-operatively, and the emergency physician must be aware of subtle signs and symptoms that may point to this diagnosis requiring early surgical consultation. These include fever, increasing abdominal pain, back pain, pelvic pressure, hiccups, unexplained tachycardia, and restlessness. A pulse rate that remains above 120 beats/min has been associated with gastric dilatation and leak with peritonitis (29). Given the seriousness of this complication and the vague nature of the presenting symptoms, suspicion of this diagnosis should lead to early surgical consultation. Radiologic contrast studies (upper gastrointestinal series) are essential to aid in the diagnosis of post-operative leak. These are routinely performed as part of the post-operative management of bariatric surgery patients to define the post-operative anatomy and to assess for leak, ileus, or obstruction. However, radiologic contrast studies can be non-diagnostic and are not extremely sensitive for anastomotic leak, and often, re-exploration in the operating room is performed early in the evaluation if this diagnosis is suspected. Initial reports of complications with laparoscopic procedures demonstrated higher anastomotic leaks, but as surgeons are becoming more experienced with the procedures, complication rates are decreasing (30).

Table 1.

Surgical Complications of Bariatric Procedures

Early complications (within 30 days of surgery)

Anastamotic breakdown—Roux-en-Y gastric bypass and biliopancreatic diversion

Acute gastric distention—Roux-en-Y gastric bypass

Late complications (more than 30 days past surgery)

Incisional hernias—open bariatric surgical procedures

Internal hernias—Roux-en-Y gastric bypass

Stomal stenosis—Roux-en-Y gastric bypass

Band erosion/Migration—vertical banded gastroplasty and adjustable gastric banding

Staple line disruption—Roux-en-Y gastric bypass and biliopancreatic diversion

Early or late complication

Small bowel obstruction—Roux-en-Y gastric bypass

 

Acute gastric distention can occur after open or laparoscopic Roux-en-Y gastric bypass. This complication seems to be due to edema or obstruction at the enteroenterostomy site. Most cases develop within the first several days post-operative, and patients will present with nausea, vomiting (dry heaves), left upper quadrant bloating, and hiccups (31). Severe distention can create problems with staple lines and anastamoses. Plain radiographs may demonstrate significant gastric distension with air-fluid levels. Percutaneous decompression has been successful in some, whereas others require re-operation with gastrostomy tube placement (28). There is some controversy as to whether nasogastic tube decompression is warranted should distention of the proximal pouch or small bowel obstruction be found. A distended remnant stomach will not be decompressed by a nasogastric tube. It is prudent to discuss this intervention with a consulting surgeon before placement in the ED due to the potential risk for puncturing suture lines.

Incisional hernias occur in 15–20% of patients after open gastric bypass, and lack of this complication is one of the major advantages of the laparoscopic approach (28). However, given the body habitus of patients undergoing gastric bypass surgery, hernias can at times be hard to palpate, and imaging by computed tomography may be required to make the definitive diagnosis. Unless the patient is symptomatic from the hernia due to incarceration or strangulation, it has been suggested to wait for maximal weight loss before repair. A hernia repair and panniculectomy (excision of excessive skin and subcutaneous tissue post weight loss) can then be completed as one procedure (28). Incarcerated hernias can occur at port sites as well and are difficult to appreciate on examination. In one of the author’s experience, they are a cause of early morbidity and need for re-operation.

Internal hernias can occur after Roux-en-Y gastric bypass; they are said to occur in up to 6% of patients (32). Internal hernias can develop in the transverse mesocolon where the limb passes through, around the mesentery of the roux limb, or in the mesenteric defect at the enteroenterostomy (28). They have been reported to occur more frequently with the laparoscopic approach (33). These hernias are difficult to identify both clinically and radiographically. As with any patient, pain out of proportion to examination should alert the clinician to the possibility of bowel ischemia. Radiographic studies are often non-specific, and surgical intervention for visualization may be necessary (28). A dilatated gastric remnant and oral contrast refluxing into the remnant may suggest internal hernia or distal obstruction.

Stomal stenosis occurs in up to 12% of both gastric bypass and vertical banded gastroplasty procedures and typically occurs 1 or more months after surgery, with a mean of 49 days after Roux-en-Y gastric bypass ([34], [35] and [36]). The gastric outlet of both procedures is typically designed to be 1 cm in diameter. Stenosis of the outlet can lead to symptoms of post-prandial epigastric pain and vomiting. Treatment involves endoscopy with balloon dilatation. Some patients require multiple dilatations.

Band erosion into the stomach after gastric banding has been reported in 0.3–1.9% of patients. Patients with this complication may present with progressive left upper quadrant pain or pain in the left lower chest that can mimic complaints of angina (22). Outlet obstruction can also lead to severe gastroesophageal reflux and esophagitis. Conversion to a gastric bypass may be required to resolve this complication.

Small bowel obstruction may occur in the early or late post-operative period. It has been described in up to 5% of patients after Roux-en-Y gastric bypass. Etiologies include adhesions, internal hernia, and intussuception (27). As in other post-operative patients, flat and upright plain radiography of the abdomen will often reveal this diagnosis. Great care needs to be taken in nasogastric decompression of these patients due to the potential for suture line and anastamotic puncture. Although the incidence of small bowel obstruction seems to be lower in the laparoscopic approach, there is an increased risk of internal hernia with laparoscopic technique. Most hernias are diagnosed more than 1 month after surgery (37). Diagnosis can be made with the use of plain radiography.

Staple line disruption is a complication of Roux-en-Y gastric bypass and vertical banded gastroplasty and is more of a weight-loss complication than a surgical complication. This may occur in the early post-operative period, but more commonly occurs 4 or more months after surgery (27). This complication allows the excluded stomach to communicate with the gastric pouch, which can lead to inadequate weight loss. It may manifest as a fistula between the pouch and gastric remnant on a contrast radiologic study. Patients may also present to the ED with complaints of gastrointestinal bleeding, which may be attributed to bleeding from the suture line of the Roux-en-Y gastric bypass limb. This complication may require aggressive management, including large-bore intravenous access and fluid and blood resuscitation, given the decreased oral intake of gastric bypass patients and the resultant potential acceleration of the deterioration in volume status (31).

Pulmonary Complications

Deep vein thrombosis with resultant pulmonary embolism is the second most common cause of death after bariatric surgery, with an incidence of 2% and a mortality of 20–30%, and does not seem related to the type of surgery ([28] and [31]). This can occur in the immediate post-operative period and as long as a month after the procedure (28). The ED algorithm for diagnosis of thromboembolic disease is unchanged in the post-operative patient. However, post-operative leaks or peritonitis may masquerade as a pulmonary complication with tachycardia and tachypnea. In one study, those with tachycardia and respiratory distress had a 20% incidence of anastamotic leak (38).

Nutritional Complications

Malnutrition is uncommon in patients with restrictive procedures, such as vertical banded gastroplasty, but does occur with malabsorptive procedures. Iron and calcium are absorbed in the duodenum, which leads to these deficiencies in the bypass patient. Iron-deficiency anemia has been described in 20–49% of patients (30). Treatment is with ferrous sulfate. Studies have also demonstrated that between 26% and 70% of patients may develop vitamin B12 deficiencies (30). This is thought to occur due to the failure of food-bound vitamin B12 to be cleaved in the upper gastric pouch (31). Patients undergoing malabsorptive procedures are typically placed on multivitamins as well as calcium supplementation post-operatively. Individuals who have undergone gastroplasty are less likely to develop these complications as opposed to the gastric bypass patient.

Malabsorptive procedures such as the biliopancreatic diversion can cause protein calorie malabsorption in 7.7–11.9% of patients (4). In one series, at 2-year follow-up, 33% of patients undergoing biliopancreatic diversion had developed anemia (28). Hypoalbuminemia also has been described (39). Biliopancreatic diversion with duodenal switch demonstrates a lower incidence of protein-calorie malnutrition, with 2–3% of patients developing problems (28).

Hepatobiliary Complications

Gallstone formation after bariatric surgery is common. It is felt to be related to the rapid weight loss and resultant bile stasis with biliary sludge formation. The incidence of sludge in the gallbladder is up to 50% at post-operatively, with an incidence of gallstones at 32% (40). Prophylactic treatment with urosodiol for 6 months after surgery has been shown to reduce the incidence of gallstones to 2% ([40] and [41]). After a Roux-en-Y gastric bypass, access to the biliary tree may be impossible via endoscopic retrograde cholangiopancreatography. Thus, the diagnosis of choledocholithiasis becomes problematic. Prophylactic cholescystectomy is performed by some surgeons, whereas others believe it increases operative complications (4). If this diagnosis is suspected in the ED, abdominal ultrasonography can aid in making the diagnosis along with adjunctive laboratory testing such as liver function tests, complete blood cell count, and pancreatic enzyme evaluation.

Gastrointestinal Complications

Stomal ulceration has been demonstrated in up to 15% of gastric bypass patients, although the etiology is unclear. Patients typically present within the first 90 days after surgery and complain of severe dyspepsia, burning retrosternal pain, and vomiting. Ulceration is diagnosed by direct visualization with endoscopy. Treatment involves proton pump inhibitors, carafate or sucralfate, and antibiotics if the patient is found to be H. pylori positive (28).

Dumping syndrome, in which the patient complains of pain, satiety, nausea and vasomotor symptoms (diaphoresis, weakness, dizziness, flushing), is commonly seen in gastric bypass patients. It has been described in up to 75% of patients. Some attribute the success of the procedure to this effect, because it deters the ingestion of calorie-dense liquids, but this has not been well established (4). Small frequent meals, dry meals, avoidance of simple sugars, and various other dietary modifications have been advocated to help control symptoms. In severe dumping syndrome, octreotide has been recommended to slow gastric emptying (42).

Neurological Complications

A 1987 retrospective review by Abarbanel et al. reported that 23 of 500 (4.6%) patients undergoing a bariatric surgical procedure experienced neurologic complications. The symptoms occurred anywhere from 3 to 20 months post-operatively. All of the affected patients experienced protracted vomiting. Patients also presented with neuropathies, myopathies, encephalopathy, and burning feet (43). More recent studies found that 48 of 556 (8.6%) patients who had undergone bariatric surgery had complications of the peripheral nervous system. These complications included mononeuropathies (carpal tunnel syndrome being most common), peripheral neuropathies, plexopathies, and myopathy (44). A deficiency of vitamin B1 (thiamine) is felt to be a major contributor to the neurologic complications. A recent review notes that at least 30 cases worldwide of Wernicke encephalopathy after bariatric surgery have been published and that this condition is mostly seen within 8 to 15 weeks after surgery (45).

Conclusion

More and more patients are turning to surgical management for weight loss. Despite decreasing complication rates, the sheer number of procedures being performed guarantees that more post-operative patients will be seen in EDs across the country. It is imperative that emergency physicians be vigilant in the evaluation and management of these patients. A thorough search for complications, even in patients with benign physical examinations, is important. Early surgical consultation will also aid in the emergency evaluation and treatment of bariatric surgery patients.

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