A 41-year-old woman presents with intermittent, crampy abdominal pain, nausea, and decreased oral intake that began earlier that morning. She reports the pain comes in waves and occasionally radiates to her back. She underwent a Roux-en-Y gastric bypass (RYGB) 18 months ago. Her temperature is 37.1°C, heart rate is 114 beats/min, and blood pressure is 128/76 mm Hg. Abdominal examination reveals only mild diffuse tenderness without guarding or rebound.
Which of the following is the most appropriate next step?
- Prescribe ondansetron and discharge with return precautions
- Order an abdominal radiograph and discharge if normal
- Prompt referral to the emergency department for computed tomography (CT) and bariatric surgical consultation
- Start a proton-pump inhibitor and arrange outpatient gastroenterology follow-up
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Correct answer: c. Prompt referral to the emergency department for CT and bariatric surgical consultation.
Rationale: Patients with a history of RYGB are at risk for internal hernias, which may present months to years after surgery. Internal hernias often present with minimal examination findings and nonspecific symptoms, and tachycardia may be the only early clue. Persistent tachycardia in this patient is a red flag that should not be attributed to pain or mild dehydration without advanced evaluation and imaging. These patients require urgent CT and bariatric surgical evaluation; thus, prompt referral to the emergency department is the most appropriate management.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
