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Difficulty: MediumGastrointestinal and Abdominal Surgery

Match each clinical presentation in a patient with a history of Roux-en-Y gastric bypass to the most likely postoperative complication.

  • Tachycardia, tachypnea, fever, and left shoulder pain occurring 3 days post-operativelyAnastomotic leak
  • Crampy, episodic abdominal pain, nausea, vomiting, and lack of flatus occurring 2 years post-operativelyInternal hernia
  • Burning epigastric pain, nausea, and melena occurring 6 months post-operatively in a patient who recently resumed smokingMarginal ulcer
  • Nausea, abdominal cramps, diarrhea, palpitations, and diaphoresis occurring 15-30 minutes after consuming a meal high in simple carbohydratesEarly dumping syndrome

Answer

The presentations match the following complications: Anastomotic leak (early post-op sepsis and Kehr sign), Internal hernia (late obstruction), Marginal ulcer (pain and bleeding associated with smoking), and Early dumping syndrome (postprandial vasomotor and gastrointestinal symptoms).
Each presentation matches precisely with the pathophysiology of the bariatric complication: early systemic inflammatory response for anastomotic leak, delayed mechanical obstruction for internal hernia, mucosal erosion at the anastomosis for marginal ulcer, and postprandial fluid shifts for dumping syndrome.

Step-by-Step Solution

1
Analyze the timing of the presentation relative to the surgery.
Early symptoms (days) point to acute surgical complications like leaks, while late symptoms (months to years) point to anatomical changes (hernias) or mucosal issues (ulcers). Meal-related symptoms point to physiological changes (dumping syndrome).
Timing is a key distinguishing factor for post-bariatric surgery complications.
2
Evaluate the specific signs and symptoms for each presentation.
Systemic inflammatory signs indicate a leak. Obstructive symptoms indicate a hernia. Bleeding and localized pain with a risk factor (smoking) indicate an ulcer. Vasomotor symptoms temporally related to high-carbohydrate meals indicate dumping syndrome.
Matching the pathophysiological mechanism to the clinical phenotype confirms the diagnosis.

Key Concept

Recognizing the timeline and specific clinical features of common complications following Roux-en-Y gastric bypass.
Estimated Time:1m 30s
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Topics

Gastrointestinal and Abdominal Surgery

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