2772 Choleperitoneum Due to Gastric Perforation Masquerading as Acute Pancreatitis in a Roux-En-Y Gastric Bypass Patient

Abstract

INTRODUCTION: Approximately 200,000 patient undergo weight loss surgery in the United States annually. Nearly half undergo Roux-en-Y gastric bypass (RYGB). After RYGB, bile acid may reflux into the gastric remnant resulting in inflammation and occasionally, perforation. The prevalence of this complication in RYGB is under 1%. We present a patient with RYGB who was initially diagnosed with pancreatitis. When the patient did not respond to treatment, reevaluation revealed gastric perforation resulting in choleperitoneum. Physicians should be aware of complications related to weight loss surgery. CASE DESCRIPTION/METHODS: A 68-year-old lady with RYGB, cholecystectomy, and osteoarthritis, recently treated with naproxen 500 mg BID, presented with sudden onset sharp, continuous, 8 / 10, epigastric pain radiating to the right upper quadrant. She had no alleviating or aggravating factor. She had no associated nausea, vomiting, sweats or chills. Vital signs were unremarkable. Her abdomen was not distended. BS present. She had no pain to percussion, but tender to palpation in the epigastric region. Initial labs demonstrated WBC 14,800/mm3, AST 12 U/L; ALT 21 U/L; amylase 1,761 U/L and lipase 926 U/L. CT demonstrated a small volume of ascites, but no fat stranding or inflammation of the pancreas. A clinical diagnosis of pancreatitis due to naproxen was made. Despite conservative treatment, the patient deteriorated. Her abdomen became distended. Repeat CT demonstrated a large volume of ascites. Analysis of ascitic fluid revealed RBC 2/mm3; WBC 4/mm3; albumin 1.1 gm/dL with SAAG 0.9 gm/dL; and total bilirubin 7.5mg/dL. Choleperitonitis was diagnosed. Emergent laparotomy revealed a gastric perforation of the remnant stomach which was surgically repaired. DISCUSSION: Choleperitoneum is defined as the presence of bile in the peritoneum. An ascitic fluid bilirubin concentration greater than 6 mg/dL with an ascitic fluid/serum bilirubin ratio greater than 1.0 is diagnostic. Etiologies include liver laceration, gall bladder rupture, or bile duct leak. Amylase and lipase may be elevated. The clues suggesting an alternative diagnosis to pancreatitis was the sudden onset of pain (consistent with rupture of viscus) and normal appearing pancreas on CT despite elevations of amylase and lipase and a small collection of ascites. Physicians should keep in mind the prevalence and complications of weight loss surgery when evaluating abdominal pain.