Assessment and treatment of abdominal pain in the bariatric patient Presented by Angela Christopherson CNP

Disclosures I am a fulltime employee of Regional Health

Topics Prevalence of Bariatric Surgery Expected outcomes Obtaining a history Gastric banding Sleeve Gastrectomy Roux en Y Gastric Bypass

Prevalence of Bariatric Surgery 2011 2012 2013 Roux en-Y Gastric Bypass 36.7% 37.5% 34.2% Sleeve Gastrectomy 17.8% 33.0% 42.1% Gastric Banding 35.4% 20.2% 14.0% Total 158,000 173,000 179,000 Reference: American Society for Metabolic Surgery (2014). New procedure estimates for bariatric surgery: What the numbers reveal. Retrieved from http://connect.asmbs.org/may-2014-bariatric-surgery-growth.html

Expected Outcomes EWL Roux en-Y Gastric Bypass 61.2% Sleeve Gastrectomy 55.4% Gastric Banding 47.5% Reference: Forse, A & Apovian, C. (2016). Bariatric Surgery: What Every Provider Needs to Know. Thorofare, NJ: SLACK; 79-109.

Laparoscopic Adjustable Gastric Banding (LAGB) Placement of an adjustable band on the upper portion of the stomach creating a small stomach pouch above the band Reduces hunger and creates fullness allowing patients to eat fewer calories (ASMBS, 2014). Reference ASMBS (2014).Bariatric surgery procedures. Retrieved November 21, 2014 from http://asmbs.org/patients/bariatric-surgery-procedures

Gastric band Port attached to the anterior rectus sheath.

Advantages Reduces the amount of food the stomach can hold Does not involve cutting the stomach or intestines Shorter hospital stay (outpatient or 1 night stay) Is reversible and adjustable Has the lowest risk of early complications and mortality among bariatric procedures Has the lowest risk of vitamin/mineral deficiencies Expected 40-50% excess weight loss Reference ASMBS (2014).Bariatric surgery procedures. Retrieved November 21, 2014 from http://asmbs.org/patients/bariatric-surgery-procedures

Disadvantages Requires foreign object to be placed in the body Requires strict adherence of post operative diet recommendations Possibility for mechanical problems of the band Possibility of slippage, erosion or infection of the port or band Slower weight loss than other procedures Reference ASMBS (2014).Bariatric surgery procedures. Retrieved November 21, 2014 from http://asmbs.org/patients/bariatric-surgery-procedures

early Post Operative Concerns Most common post operative concerns include nausea and dehydration Mortality is 0.1%-most often attributed to cardiac event or pulmonary emboli Rarely: bleeding, infection or internal organ injury….Consider these if patient presents with fever and pain Reference: Forse, A & Apovian, C. (2016). Bariatric Surgery: What Every Provider Needs to Know. Thorofare, NJ: SLACK; 79-109.

Long Term concerns Device malfunction: port migration, port infection, tubing disconnection, tubing kink or port leak Band Erosion: often happens years after implantation although can happen earlier. Patient often asymptomatic but can present with lack of satiety despite optimal adjustment or with cellulitis over the access port. Diagnosed with endoscopy and requires band explantation. Band Slip (Pouch Enlargement): Presents with heartburn, reflux, dysphagia or intolerance to food. Caused by portion of the pouch lying dependent over the band resulting in improper emptying. Diagnosed with barium swallow esophagram. Treatment includes loosening of the band and PPI or sucralfate. Often needing surgical revision. Esophageal Dilation: Presents with dysphagia. Diagnosed on esophagram. Treated with band deflation. Reference: Forse, A & Apovian, C. (2016). Bariatric Surgery: What Every Provider Needs to Know. Thorofare, NJ: SLACK; 79-109.

CASE STUDY #1 -45 year old female with h/o lap band presents with dysphagia for 4 months. She reports she has been waking up at night coughing for the past two weeks occasionally vomiting. She noticed yesterday that when she vomited at 2am her morning medications came up.

Work up Assess: When and where was the lap band placed? When was the last time the patient had any adjustments to her lap band? What is she eating? Quantity? How quickly? How close to bedtime is she eating her last meal? Daytime reflux? Taking PPI? Abdominal pain or fever? DDX: Maladaptive eating, reflux, overly tightened lap band, lap band slip Treatment: Refer patient to bariatric surgeon who performed her surgery if possible or nearest professional trained in lap band adjustments. Patient will likely have fluid removed from her band and possible barium esophogram to verify location of band

Case Study #2 56 year old male presents with c/o heartburn for 3 months worsening over the last month. He states that in the last week he has vomited daily. He has lost over 100 pounds with lap band surgery and has not needed to see his bariatric surgeon in over 1 year. He is very resistant to having fluid removed from his lap band because he has done so well with maintaining his weight.

Work up Assess: When and where was lap band placed? Intake: what, when and how much is he eating? Is he taking any OTC medications for his symptoms? DDX: GERD, pouch dilatation, lap band slip, maladaptive eating Treat: Refer to patients bariatric surgeon or nearest professional trained in lap band adjustments. May consider starting PPI but patient most likely needs some fluid removed from his band

Case Study # 3 38 year old female presents with redness and tenderness over her lap band port. Denies having her port recently accessed and is not having any nausea, vomiting or heart burn.

Work up Assess: Infection localized? Difficulty eating? Adequate restriction? DDX: port site infection, lap band erosion Treat: May start oral antibiotics. Send referral for endoscopy to r/o erosion

Laparoscopic Sleeve Gastrectomy (LSG) Is performed by removing 80% of the stomach creating a tubular stomach pouch Causes weight loss by restriction of food intake (fewer calories in) and also because of changes in hormones causing decreased hunger, earlier satiety and better control of blood sugars Reference ASMBS (2014).Bariatric surgery procedures. Retrieved November 21, 2014 from http://asmbs.org/patients/bariatric-surgery-procedures

Advantages Restricts the amount of food the stomach can hold Causes rapid weight loss with comparable to the gastric bypass (>50% EWL) Does not require a foreign object to be placed in the body Short hospital stay (typically 1 night) Changes gut hormones causing decreased hunger, suppresses appetite and causes earlier satiety Reference ASMBS (2014).Bariatric surgery procedures. Retrieved November 21, 2014 from http://asmbs.org/patients/bariatric-surgery-procedures

Disadvantages Is non reversible Can cause long term vitamin deficiencies Higher complication rate than gastric banding Can have complication such as: Leakage Bleeding Stricture Reference ASMBS (2014).Bariatric surgery procedures. Retrieved November 21, 2014 from http://asmbs.org/patients/bariatric-surgery-procedures

Immediate concerns Gastric Staple line leak- Typically present with unexplained elevated WBC, tachycardia, fever, abdominal pain or persistent hiccups. Imaging includes CT scan of Chest and abdomen with IV/PO contrast or surgical re-exploration (ASMBS, 2015) GI Bleed- Presents with drop in hct, tachycardia, hypotension. Low incidence. Gastric outlet obstruction Early stricture Surgical Site infection Early postop Small Bowel Obstruction References: ASMBS (2015). Prevention and Detection of Gastrointestinal Leaks. Retrieved from https://asmbs.org/resources/prevention-and-detection-of-gastrointestinal-leak

Long term concerns Leak or fistula Stricture Gastric outlet obstruction Portal/mesenteric vein thrombosis Gallstones Severe GERD

LSG Case Study #1 42 year old female presents with fatigue, reported inability to get fluids down and decreased urine output. She reports bariatric surgery 5 days ago. She states she is able to sip on fluids but doesn’t feel like she is getting in enough fluids. She also reports some nausea but denies vomiting. She reports she is passing gas and had a small BM 2 days ago. Patient is afebrile, B/P 136/64, HR 96, RR 18 PE: Abdomen obese, soft, BS+. Incisions healing without signs of infection.

Work UP Assess- What type of surgery did the patient have? Is patient tolerating any fluids? Does she have Rx for antiemetic, is she using them? Is she having pain? Incisional vs. Visceral. Bowel function? Abdominal assessment. Has patient contacted bariatric surgeon? Treat: Check CBC, CMP. IV LR or NS 1-2liters. IV antiemetic vs. Oral dissolving. Contact Bariatric surgeon.

LSG Case Study #2 38 year old male presents with generalized abdominal pain. He is 1 week s/p bariatric surgery. He reports he has been able to get small amounts of liquids down and feels a little bloated. He denies fever, has been taking his pain medications routinely for pain. VS: 120/84, HR 122, RR 18, T 98.6

Work Up Assess: What type of bariatric surgery did he have? How much liquid is he tolerating? Last BM? Abd exam? Has he contacted his surgeon? Diagnostics: CBC, CRP. CT with IV and water-soluble PO contrast. Contact bariatric surgeon!! Avoid endoscopy if patient <4 weeks post-op.

LSG CaSE STUDY #3 23 year old female 4 months s/p bariatric surgery presents with nausea and vomiting. She has lost 70 pounds since her surgery. She had been tolerating solid food until the last month. She reports she can tolerate liquids without difficulty but vomits most solids. She reports some constipation. She is not having any pain. Her VS are unremarkable.

Work UP Assess: What type of bariatric surgery did he have? How much liquid is she tolerating? Last BM? Abd exam? Treat: Increase fluids, laxatives, fiber, activity. Consider endoscopy to r/o stricture.

Gastric Bypass (GB) First a small stomach pouch is created by dividing the top of the stomach from the rest of the stomach. Next the intestines are divided and connected to the new stomach pouch Works by allowing less intake, the change in the intestines causes less absorption of calories and nutrients and changes in the way food moves through the stomach and intestine. Changes in gut hormones producing earlier satiety, suppressing huger and changing the way obesity induces type 2 diabetes Reference ASMBS (2014).Bariatric surgery procedures. Retrieved November 21, 2014 from http://asmbs.org/patients/bariatric-surgery-procedures

Advantages Produces significant long term weight loss (60-80% EWL) Restricts the amount of food that is consumed Produces changes in gut hormones that cause satiety and reduces appetite Reference ASMBS (2014).Bariatric surgery procedures. Retrieved November 21, 2014 from http://asmbs.org/patients/bariatric-surgery-procedures

Disadvantages More complex surgery than the Gastric band and sleeve, with more complications Can lead to long term vitamin/mineral deficiencies Longer hospital stay Requires adherence to strict dietary recommendation Requires lifelong adherence to vitamin and mineral supplementation Reference ASMBS (2014).Bariatric surgery procedures. Retrieved from http://asmbs.org/patients/bariatric-surgery-procedures

Immediate concerns (1-4 weeks) Anastomotic leak GI bleed Early stricture Surgical site infection Early small bowel infection

Long term concerns (>30 days) Internal herniation and SBO-SBO is often caused by internal herniation. Stricture-Typically occur at 4-6 weeks post op (can be later) noted with progressive intolerance to solids Marginal Ulcer-Most common in smokers and NSAID use. Common symptoms include epigastric pain with eating or spontaneous perforation. Reference: Martin, Matthew. (n.d.). Acute Care Surgery Emergencies in the Bariatric Patient: Syllabus. Retrieved from https://webcache.googleusercontent.com/search?q=cache:CYw5VMFde8kJ:https://www.east.org/content/documents /43_bariatric_syllabus.pdf+&cd=1&hl=en&ct=clnk&gl=us

Internal Herniation Most commonly occurring through the mesenteric defect of the jejunjejunostomy or at Peterson’s defect (potential space posterior to a gastrojejunosotmy) Symptoms can be mild and non specific. Not always identifiable on CT scan. Can occur at any time after surgery Reference: De Bakker, J. K., van Namen, Y. W. B., Bruin, S. C., & de Brauw, L. M. (2012). Gastric Bypass and Abdominal Pain: Think of Petersen Hernia. JSLS : Journal of the Society of Laparoendoscopic Surgeons, 16(2), 311–313. http://doi.org/10.4293/108680812X13427982376581

Stricture Present at >4 weeks post-op Presentation usually includes progressive intolerance to solids but will often tolerate liquids EGD is diagnostic of choice Reference: Martin, Matthew. (n.d.). Acute Care Surgery Emergencies in the Bariatric Patient: Syllabus. Retrieved from https://webcache.googleusercontent.com/search?q=cache:CYw5VMFde8kJ:https://www.east.org/content/documents /43_bariatric_syllabus.pdf+&cd=1&hl=en&ct=clnk&gl=us

Marginal Ulcer Ulceration at the gastrojejunosotomy. Incidence 2-15% Typical presentation of epigastric pain with eating Typically heal with acid suppression and cessation of smoking and NSAID use. Patients can present with abdominal pain, nausea, vomiting, hematemesis, stomal obstruction or perforation Medical management includes PPI and sucralfate for 3 to 6 months. Also rule out of H. Pylori infection and treatment if indicated. Reference: Martin, Matthew. (n.d.). Acute Care Surgery Emergencies in the Bariatric Patient: Syllabus. Retrieved from https://webcache.googleusercontent.com/search?q=cache:CYw5VMFde8kJ:https://www.east.org/content/documents /43_bariatric_syllabus.pdf+&cd=1&hl=en&ct=clnk&gl=us

Key Considerations Identify the type of surgery the patient had as bariatric procedures often get referred to as gastric bypass. Identify patient eating behaviors. Maladaptive eating can contribute to many abdominal complaints after bariatric surgery. The patients bariatric surgeon should be contacted with concerns. They are your best resources when dealing with many abdominal complaints.

Cont… Significant weight loss contributes to occurrence of gallbladder disease. Consider this in your differential. Constipation is a common problem in patients s/p bariatric surgery as the patients diets are typically low in fiber and high in protein. Calcium supplementation and decreased fluid intake can also contribute. Not all health conditions are associated to a patients surgical procedure. Common problems still occur in these patients.

If the patient is less than 4 weeks s/p bariatric surgery think “LEAK” either anastomotic or staple line. Mild elevation in WBC’s, tachycardia and fever can all indicate a leak. Many abdominal complaints with the adjustable gastric band can be relieved with deflation of the band!!

Other Considerations Vitamin and mineral deficiencies: B12, thiamine, iron, Vitamin A,E,D,K, Zinc and Copper. Can occur acute or chronically. Consider psychological differentials.

Thank You!!