1. Acute Management of Patients with a Prior History of Bariatric Surgery

2. 34 year old female found unresponsive

3. Bariatric Surgery Types
Gastric Bypass
Sleeve Gastrectomy
Lap-Band—rarely performed now
VBG (Gastric Stapling)—obsolete
Molina Band—obsolete
Other: (Duodenal Switch, BPD) —rare

4. 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

5. 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.

6. 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

7. 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

8. 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

9. Common Symptoms Abdominal Pain Chest Pain Nausea/Vomiting GI Bleeding
Weakness
Shortness of Breath
Bloating
Illness/Injury unrelated to bariatric anatomy

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

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

25. 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

26. 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

27. Test Question
NSAIDS (Cox-1) are contraindicated in gastric bypass patients, regardless of an oral or intra-venous route
a. True
b. False

28. 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

29. Test Question
The bariatric surgeon should be notified if a Lapband patient presents with persistent vomiting
a. True
b. False