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Intern Report Collection, Vol. 7

To kick off your weekend reading pleasure, here’s another batch of our monthly excellent write-ups from the EM interns at UT Southwestern (@DallasEMed) courtesy of Alex Koyfman (@EMHighAK) . Our ongoing intern report series is the product of first-year residents exploring clinical questions they have found to be particularly intriguing, with an intended audience of med students & junior residents. Enjoy!

practice updates

Power Review: Management of the Post-Bariatric Surgery Patient

Your next 3 patients… #1: Gastric bypass pt with SIRS criteria #2: Gastric bypass pt with psychiatric complaints #3: Gastric bypass pt with nausea/vomiting The Basics -Morbid obesity continues to rise significantly (epidemic) -Increasing # of weight-loss surgeries w/ physical/psych effects => increasing ED visits for postoperative complications -Increased laparoscopic techniques; each surgical option w/ potential complications -2 main strategies of surgery: gastric restriction (early satiety) => banding / gastroplasty; intestinal malabsorption (bypass parts of small intestine) => distal gastric bypass / biliopancreatic diversion +/- duodenal switch -Hospital stays: 3-4 days Clinical Pearls -Challenging / unreliable abdominal exam => more extensive work-ups including CT abdo/pelv w/ oral + IV contrast (drink over several hours) -May not fit into CT scan -Often don’t manifest symptoms/signs of serious intra-abdominal pathology i.e. signs of peritonitis masked by large amount of intra-abdominal fat -Lack cardiopulmonary physiologic reserve => quick deterioration; get surgery involved early -Concern for band migration: need swallow study under fluoroscopy -Roux-en-Y pts are tricky b/c part of small intestine is bypassed; signs/sxs not classic and abdo XR not reliable -Fever + tachycardia + increasing abdominal / back pain in Roux-en-Y pt in 1st several weeks post-surgery, pursue anastomotic leak/intra-abdominal abscess; need UGI series vs surgical exploration -Upper endoscopy has a role in diagnosing bleeding / stricture / stenosis -Internal hernia: tough dx; many w/ normal labs / XR / UGI series / CT; surgical exploration needed [...]