Clinical Vignettes/Case Reports-Obesity.

Abstract

Bariatric surgeries of all types, including laparoscopic adjustable gastric band (LAGB), have gained large popularity in the past few decades as an effective method of weight loss in morbidly obese patients. Such procedures carry multiple short and long term complications. Rare and difficult to recognize surgical complications may have a significant impact on patient's quality of life and health-care cost. We report a case of a 62 year-old woman who presented to the hospital seven years after successful LAGB surgery with several months of cough, shortness of breath, and episodes of nausea associated with vomiting. She is a non-smoker and has a history of obstructive sleep apnea. Recent history is pertinent for multiple episodes of pneumonia treated with antibiotics in the outpatient. CT chest revealed extensive innumerable tiny nodular bilateral infiltrates with no significant adenopathy. It also showed distended esophagus with fluid content. Patient subsequently got admitted for further evaluation and management of her worsening symptoms. Initial workup for possible respiratory bacterial, fungal and mycobacterium infections were negative. Patient underwent extensive work up with bronchoscopy which showed erosive inflammation in various stages in the posterior oropharynx. Trans-bronchial biopsy from the right lower lobe showed inflammatory cells with no malignant cells. It also showed the presence of Enterobacter Cloacae (gut flora) on the bronchoalveolar lavage, suggestive of aspiration pneumonia. Esophagogastroduodenoscopy (EGD) showed distal migration of the gastric band, resulting in gastric retention (See image 1 & 2). Patient was then transferred to a tertiary care center where she underwent uncomplicated surgical removal of the gastric band with complete resolution of her symptoms. There have been only few reported cases of chronic cough as a long term complication of gastric band surgery. Chronic cough associated recurrent aspiration pneumonia in a patient with history of gastric band surgery should raise the suspicion of band slippage. Pathophysiology suspected is micro aspiration of acid leading to pneumonitis eventually predisposing to recurrent pneumonia and chronic cough. Early suspicion can help recognize the condition as removal of the band can result in complete resolution of symptoms.Figure: Distal esophageal dilatation with fluid stasis.Figure: Slipped band with errosions into the mid body part of the stomach.