A 50-year-old man with a history of hypertension, active smoking, and a laparoscopic Roux-en-Y gastric bypass 5 years prior presents to the emergency department with 4 weeks of upper abdominal pain that acutely worsened on the morning of presentation. He:
His abdomen is diffusely tender and he is guarding. He has:
Blood cultures are sent and broad-spectrum antibiotics administered. A CT scan shows a moderate amount of free fluid in the upper abdomen.
What is the BEST definitive management of this patient?
A. Admission to the intensive care unit for serial abdominal examinations and intravenous antibioticsCorrect Answer: D
The patient in this scenario has a perforated marginal ulcer. A marginal ulcer is a known complication of Roux-en-Y gastric bypass surgery at the anastomosis between the gastric pouch and the jejunum. An ulcer is usually formed on the jejunal side, and the greatest risk factor for marginal ulcer formation is smoking. As with all patients who present with intestinal perforation, a perforated marginal ulcer must be recognized promptly. As in this situation, patients with intestinal perforation may not present with the classic finding of “free air” on CT scan or abdominal Xray. Instead, they may have free fluid or fat stranding. In patients who present with peritonitis and manifest the hemodynamic effects of sepsis, even with more subtle CT findings, clinical suspicion for perforation must be high and these patients should be taken to the operating room urgently.
In this case, the patient has peritonitis and is septic, and solely admission to the ICU with serial examinations and antibiotics is not appropriate in the absence of operative intervention. Although nasogastric tube placement is reasonable, this is not sufficient to treat the underlying problem of a perforation. Endoscopy is appropriate for outpatient evaluation of a suspected marginal ulcer in a patient with occult anemia or pain, but it is not indicated in the setting of perforation. Finally, while the patient is tachycardic, she has no melena or hematochezia to suggest that she is bleeding. Although marginal ulcers can present with bleeding, particularly in patients on anticoagulation, those patients generally do not also present with peritonitis. Because this patient is not bleeding, a consult to interventional radiology for angioembolization would not be helpful.
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