IBC Discussion

  • tom

    Do you think, in the future, bariatric surgery will split off metabolic surgery?

  • tom

    What is best strategy to avoid biliary reflux in MGB?

  • what is your strategies to avoid leak from sleeve gastrectomy?

  • How do you secure stapler line in sleeve gastrectomy?

  • Piotr Mysliwiec

    Please help me resolve a clinical problem.

    Postprandial pain and hypoglycemia 5 years after RYGB?

    A 30 years old woman, complaining of
    The patient suffers from postprandial pain, nausea and abdominal distention (predominantly in the hypgastric area) after most foods. She complains of fatigue and chronic constipation.

    The symptoms have been occuring on and off for a few years.
    Periodically (every few months) she requires in-hospital electrolyte correction and iv hydration (taking care of a small baby, she does not take a good care of herself).
    A few weeks ago she fainted and required admission to the hospital – without significant finindgs other than hypoglycemia.
    Body weight decreased from 120 to 55 kg after RYGB with present BMI of 19 kg/m2.

    The patient suffers from type 1 diabetes, recurrent urinary tract and gynecologic infections.

    2013 May – RYGB for obesity
    2013 November – Laparoscopy. Freeing of adhesions. Petersen space and intermesenteric space closure for incomplete bowel obstruction.
    2014 January – Laparoscopy due to incomplete bowel obstruction. Side to side anastomosis of alimentary and common loop next to J-J anastomosis due to obstraction of J-J anastomosis.
    A year after RYGB, despite medical advise, she got pregnant and deliered a healthy child; she required in-hospital electrolyte (K, Mg) supplementation during pregnancy.

    She smokes 20 cigarettes/day

    she went down from 120 units of insulin per day before RYGB to 20 currently.

    On examination the patients is in good general condition, the abdomen is soft, durign episodes of pain, tender in upper and mid-abdomen with normal bowel sounds and no rebound tenderness.

    Labs: slight anemia (Hb 11,2 g/dl), decreased WBC (2,75),
    Total protein (6.6 g/dl) and serum albumine (36,7g/l) remain stable within the normal range.
    The patients is usually hypoglycemic (39 mg/dl), with decreased insulin (5,8 uU/ml), however current HbA1c is 8.9%,
    CRP, procalcytonin, liver function tests, cratinin, urea – normal.

    Imaging
    Recent ultrasound demonstrated thickening of antrum up to 9,4mm, hypoechogenic; slightly thickened intestinal loops in the left mid-abdomen and hypogastric area, filled with dense fluid content, with dicreased peristalsis. A small amount of free fluid in the pelvis.
    Follow through revealed good intestinal passage, however remainings of contrast medium could be seen even 24 hours in a small bowel loop in the hypogastric area.
    Recent plain abdominal X-ray showed few short air-fluid levels in the left mid-abdomen and hypogastric area.
    Chest X-ray unremarkable.
    CT scan – metalic shadows on the left side, slightly distended cecum, otherwise unremarkable.

    Incomplete BP limb obstruction? Adhesions? Hypoglycemia?

    Plese give me your advise on HOW YOU WOULD MANAGE this patient?
    Cheers,

    Piotr

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