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The UC Davis Department of Emergency Medicine offers a two year Medical Toxicology Fellowship. You go to reassess the patient, and he develops shortness of breath when you help direct him to the location of the bathroom. Bleeding from anastomotic sites, which present with tachycardia and a drop in hematocrit, typically occur within the first few weeks after surgery. Wound infection is more common with open gastric bypass surgery, and it generally occurs 1-2 weeks post-op. Anastamotic leaks of gastric contents and GI obstruction most commonly occur 1-4 weeks post-op. Problems occurring later include internal hernias, obstruction, distention of a blind pouch, cholelithiasis, and stomal ulcers. Stomal obstruction and cholecystitis can present months to years after the initial surgery. Dumping syndrome occurs after eating simple carbohydrate meals and presents with nausea, vomiting, and generalized weakness (1). He is unlikely to have an infection, bleed, or leak and only have developed his problem 7 weeks after his surgery. Liver function tests (LFTs) and alkaline phosphatase are generally not elevated, as the common bile duct is not usually blocked during acute cholecystitis. Marchick (5) performed the best and largest study on the ECG findings in patients tested for pulmonary embolism (PE), and it included over 6,000 patients with a 6% PE prevalence rate. Like TWIs in the anterior leads, Marchick’s paper found S1Q3T3 to be poorly sensitive but highly specific for PE.
However, much earlier literature has shown that any cause of acute cor pulmonale, such as pneumothorax or acute bronchospasm, can cause this ECG finding (7).
Our patient’s tachycardia improved upon re-examination, and there is some literature to suggest that the normalization of abnormal vital signs does not reduce your pre-test probability of PE (9).
We also have a better diagnosis for RUQ pain available, but you are concerned that the clinical decision rule is not as good as your judgment.
Our patient has a Wells Score of 3, placing him at either moderate or “unlikely” pre-test probability of PE depending on how you rank the score. Gestalt has been shown to outperform wells criteria in a recent Annals of EM paper by Penezola (10), who compared unstructured clinical gestalt to the Wells and Revised Geneva scores. However, gestalt overrules the Wells Score in this obese, sedentary patient who easily develops SOB and has ECG findings highly specific for PE. Ideally, you should (have time to) perform bedside ultrasounds of the RUQ to look for acute cholecystitis, of the legs to look for DVT, and of the heart to identify right ventricle dilatation.  The sensitivity of your sonogram will be dependent on your experience, and you may not have time to sonogram multiple regions. If you found a DVT on ultrasound, would you stop and admit?  Or would you CT scan the abdomen believing that the DVT is a red herring distracting you from finding an abdominal pathology with worse consequences? The consensus from follow-up rounds was that the patient should get a CTA of the chest for PE and then look at the abdomen and pelvis to address abdominal pathology related to the gastric bypass given the high complication rate. CTA showed a considerable thrombus within the artery supplying the right lower and middle lobes.


The second case is a 55 year old man with obesity and HTN presenting with an initial ED triage complaint of diarrhea after eating a “bad meatball sandwich” earlier that night. His ECG is shown below and has ST elevations in the precordial leads with what may appear to be a left bundle branch block (LBBB). Balloon angio was performed to the LAD and D1 with TIMI grade flow improvement from 0 to 3, which means it went from no perfusion to normal perfusion. The alternative is to do a quick gastric swallow study where the patient swallows the oral contrast, gets a single view abdominal x-ray. I think your idea of having the patient drink contrast before the PE study is a smart idea if you had a patient like this presenting a few weeks after some bariatric procedure. For an anastamotic leak, they recommend a GI series with PO contrast versus a CT with contrast and state they are both sensitive enough.
For acute GI obstruction, the recommend starting with a plain film to look for a massive gastric pouch with an air:fluid level.
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These patients may present with peritonitis and eventually develop fistulas if the leak is not recognized early. Internal hernia formation results from herniation of the small bowel through potential spaces created during the surgery. Stomal ulcers can present 2-4 months post-op, and stomal stenosis is usually seen 6 months post-op. In fact, if there is even slight elevation in LFTs or alkaline phosphatase, one should consider that the common bile duct is blocked. Anterior TWIs were one of only two ECG findings the authors found to have relatively useful LRs, and the positive LR of anterior TWIs is 3.7.
They found that clinical gestalt outperformed both clinical decision rules due to higher accuracy in patients with either low or high pre-test probabilities. We have been told conflicting information from the radiology department on whether a CTA protocoled for detecting PE can simply be continued down to the abdomen and pelvis. This patient only became SOB after a repeat, albeit unintentional, re-examination while walking.
He was quickly assigned to a zone and evaluated, because his secondary complaints included nausea, vomiting, diaphoresis, and suprasternal pain radiating bilaterally to his shoulders and back. In this case, the information we learned from Tintinalli’s text may have prevented us from using the Modified Sgarbossa to “rule in” a STEMI immediately after reviewing the ECG. Bariatric Surgery: A Review of the Available Procedures and Complications for the Emergency Physician. Simultaneous T-wave inversions in anterior and inferior leads: an uncommon sign of pulmonary embolism. Normalization of vital signs does not reduce the probability of acute pulmonary embolism in symptomatic emergency department patients.


Comparison of the unstructured clinician gestalt, the wells score, and the revised Geneva score to estimate pretest probability for suspected pulmonary embolism.
Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block.
Diagnosis of ST-elevation myocardial infarction in the presence of left bundle branch block with the ST-elevation to S-wave ratio in a modified Sgarbossa rule. Electrocardiographic diagnosis of myocardial infarction in patients with left bundle branch block. The inadvertent administration of anticoagulants to ED patients ultimately diagnosed with thoracic aortic dissection. Initial Q waves accompanying ST-segment elevation at presentation of acute myocardial infarction and 30-day mortality in patients given streptokinase therapy: an analysis from HERO-2. Baseline Q-wave surpasses time from symptom onset as a prognostic marker in ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention. Gruber was very interested in discussing the best way to diagnose these post-bariatric surgery patients depending on the time of presentation. He reports weight loss after the surgery, now weighing in at 350lbs from 500lbs prior to the procedure.
Most patients with obstruction will present with a persistent inability to tolerate PO, yet the intermittent nature of the obstruction may make its detection difficult with imaging.
Rapid weight loss predisposes to gallstones, and up to 50% of gastric bypass patients develop gallstones. Furthermore, elevated LFTs do not have adequate sensitivity to dissuade you from a diagnosis of acute cholecystitis. However, this is a European study with a high PE prevalence rate (31%); and it is unclear (if not unlikely) that these results will translate into the American setting, where the prevalence in our literature is much lower. Depending on your radiologist’s confidence that the IV contrast will be timed appropriately for the abdomen and pelvis as well, you may have to perform two scans so the timing is correct. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators. Despite this weight loss, he mentions that he has “not been doing much other than playing video games” in the last few days.
The gastric pouch created during the gastric bypass can become distended from impaired emptying or from obstruction and result in rupture or spillage of bowel contents causing severe peritonitis. A change in prevalence will alter your pre-test probability and the positive predictive value (PPV) of your gestalt.
A post-surgical gastric pouch may be seen as large gastric bubble on imaging, and it may present with shortness of breath.  There is a high mortality with this blind pouch syndrome unless it is recognized early and explored operatively.



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