A 30-year-old man presents with persistent vomiting that began overnight. He underwent laparoscopic sleeve gastrectomy 10 days ago and reports he has not been able to eat or drink anything for the past 12 hours. He denies diarrhea but reports worsening upper abdominal discomfort and generalized lethargy. He is afebrile (temperature 37.8˚C) with a heart rate of 118 beats/min.
Which of the following is the most likely diagnosis?
- Anastomotic or staple-line leak
- Viral gastroenteritis
- Dumping syndrome
- Constipation
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Correct answer: c. a. Anastomotic or staple-line leak.
Rationale: Persistent vomiting accompanied by tachycardia in the early bariatric postoperative period should prompt immediate concern for a leak, even in the absence of fever or marked abdominal tenderness. Leaks most commonly occur during the first postoperative week but may present later, and physical examination findings are often subtle. Because leaks can rapidly progress to sepsis and death, this patient should be referred to a higher level of care immediately. Viral gastroenteritis, dumping syndrome, and constipation are less likely complications given the timing of surgery and the presence of persistent tachycardia and inability to tolerate oral intake.
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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.
