Acute Management of Patients with a Prior History of Bariatric Surgery - PowerPoint Presentation

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Acute Management of Patients with a Prior History of Bariatric Surgery

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34 year old female found unresponsive

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Bariatric Surgery Types

Gastric Bypass

Sleeve Gastrectomy

Lap-Band—rarely performed now

VBG (Gastric Stapling)—obsolete

Molina Band—obsolete

Other: (Duodenal Switch, BPD)

—rare

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Overview

Obtaining patient history

Symptoms related to the bariatric surgery

Procedure concerns

Medication contraindications

Tobacco/Alcohol Use

When to notify the bariatric surgeon

Discharge recommendations

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Pre-Hospital Concerns

Successful bariatric patients are difficult to identify

Bariatric GI changes can affect field medications and procedures

Symptoms may be directly related to the bariatric procedure regardless of surgical date.

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Patient History

Reasons the patient will not disclose a history of bariatric surgery:

a. Does not feel the need to disclose if the

current problem appears unrelated

b. Shame related to weight regain or non-

compliance

c. Secrecy from family and friends

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Bariatric History Information

Specific type of weight loss procedure

Date of surgery with location and surgeon’s name if available

Any history of complications

Description of follow-up compliance

Exact medication history including OTC’s

Social history with tobacco and alcohol usage

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History Helpful Tips

Try to obtain sensitive history information while alone with the patient

Suspect bariatric surgery if there is/was a history of morbid obesity

Ask specific questions about stomach surgery even when the current problem is not related

Ask

all bariatric

patients specifically about NSAID (Rx & OTC) and tobacco use

Educate the patient how this information is needed to avoid complications related to medications or procedures

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Common Symptoms

Abdominal Pain

Chest Pain

Nausea/Vomiting

GI Bleeding

Weakness

Shortness of Breath

Bloating

Illness/Injury unrelated to bariatric anatomy

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Abdominal Pain

Epigastric: Gastritis/Ulcer disease is most likely—think food obstructing the gastric bypass pouch,

lapband

, or stomach sleeve when the pain is associated with vomiting

Right Upper Quadrant: Gallbladder disease occurs more often with rapid weight loss

Generalized: Internal intestinal hernias often present with vague pain only

Lower Quadrants: Constipation or conditions unrelated to bariatric changes, i.e. appendicitis

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Abdominal Pain Considerations

The type of bariatric surgery will often dictate the evaluation and treatment

Gastric bypass patients with common bile duct stones cannot be treated with a traditional ERCP

Bariatric patients with bowel obstructions may present with pain and bloating without vomiting

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Chest Pain

Bariatric patients with stomach ulcers often present with chest pain as the only symptom

Food obstructions cause esophageal dilation and spasm, resulting in chest pain

Must rule out cardiopulmonary etiologies

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Nausea/Vomiting

Common symptom in bariatric patients <30 days post-op

The most common symptom in

Lapband

patients

Most often originates from a problem in the stomach

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GI Bleeding

Upper and lower GI bleeding can occur in bariatric patients

Gastric bypass patients with bleeding ulcers often pass bright red blood due to the rapid transit time

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Weakness

Often a symptom of dehydration

May be the presenting symptom in gastric bypass patients with a thiamine deficiency associated with vomiting or alcohol use

Consider malnourishment in bariatric patients

B-12 deficiency can cause weakness when prolonged—B-12 replacement is needed in all gastric restrictive patients due to the loss of intrinsic factor

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Shortness of Breath

Post-surgical gastric leaks will present with symptoms very similar to pulmonary embolus or congestive heart failure

A leak should be considered in any bariatric patient with shortness of breath < 30 days post-op

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Bloating

Bariatric surgery can change the GI tract anatomy, which prevents vomiting with bowel obstructions

Bloating and abdominal pain may be the only symptoms with intestinal twisting (volvulus) or blockage

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Unrelated Illness/Injury

Many ER/Hospital admissions are not related to the prior bariatric surgery

An accurate history of any bariatric procedure is needed to avoid potential injury to the stomach with procedures or medications

The bariatric history will be needed to order an appropriate diet

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Procedure Concerns

All bariatric procedures either create a narrow opening into the stomach or restrict the total size of the stomach

Misplacement and injury to the GI tract are the two most common problems with blind advancement of tubes

Gastric

tubes will rarely pass blindly through an inflated

Lapband

, resulting in the tube curling in the

esophagus

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Procedure Concerns

Blind placement of tubes in gastric bypass patients will usually result in the tube abruptly stopping at the wall of the small intestine adjacent to the stomach pouch increasing the possibility of intestinal perforation

Drug overdose--blind gastric lavage of bariatric patients is contraindicated

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Procedure Concerns

Gastric bypass patients with biliary common duct stones cannot be treated with a traditional ERCP

Oral contrasted studies of the stomach need to be modified to account for the small gastric size

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Medication Contraindications

All Cox-1 NSAIDS, both Rx and OTC, including

injectables

are an absolute contraindication in gastric bypass patients due to the high incidence of marginal ulceration

Full strength aspirin medications and oral corticosteroids should be used with caution due to the potential erosive properties

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Tobacco/Alcohol Use

Smoking tobacco causes ischemic erosions in gastric bypass patients.

Alcohol use/abuse on a routine basis increases the likelihood of gastritis and ulcers in patients with restricted stomach volume

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*****Bleeding/Perforated Ulcers in Gastric Bypass Patients are most often related to smoking tobacco or NSAID use*****

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When to notify the bariatric surgeon

All bariatric patients presenting to the ER less than 30 days after bariatric surgery

Any bariatric patient greater than 30 days post-operative presented with a bariatric-related complaint, including chest pain, abdominal pain and weakness

Any

Lapband

patient with vomiting

Any time there are concerns or questions involving the bariatric anatomy

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Discharge Recommendations

Follow

up suggested for all bariatric patients seen in the ER less than 30 days post-operative

Follow up with the bariatric clinic if the patient has not been compliant with visits

Urge the patient to stop NSAIDS and tobacco when use is detected in bariatric patients

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Test Question

NSAIDS (Cox-1) are contraindicated in gastric bypass patients, regardless of an oral or intra-venous route

a. True

b. False

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Test Question

Bariatric patients often do not reveal a history of weight loss surgery because:

a. They never told family and/or friends

about the bariatric surgery

b. They are ashamed about inadequate

weight loss

c. They believe it is not necessary to reveal

when presenting with an unrelated problem

d. All of the above

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Test Question

The bariatric surgeon should be notified if a

Lapband

patient presents with persistent vomiting

a. True

b. False