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A 31-year-old gravida 2, para 1 patient of 36 weeks’ gestation had undergone a laparoscopic Roux-en-Y gastric bypass (RYGB) 4 years ago, resulting in prepregnancy weight loss of 70 kg, or 128% of her excess weight. She awakened with severe lower back pain, abdominal pain, nausea, and vomiting. She came to the emergency department with 10/10 abdominal pain but no fever, chills, vaginal bleeding, or rupture of membranes. Her abdominal examination revealed diffuse tenderness and guarding. She was initially diagnosed as having preterm labor and was given antibiotics, steroids, an epidural catheter for pain management, and intravenous fentanyl as needed. She delivered a healthy baby without complications, but her severe abdominal pain, nausea, and vomiting persisted. Thirty-six hours after her initial presentation, she still had rebound tenderness in the left side of the abdomen. She was afebrile, blood pressure was 104/77 mm Hg, and heart rate was 152/min. White blood cell count was 10.7 ×109/L; anion gap, 13 mEq/L; and lactate dehydrogenase level, 131.7 U/L (2.2 μkat/L). A computed tomography (CT) scan of the abdomen and pelvis with oral and intravenous contrast revealed mesenteric vascular compromise (Figure 1); after the scan, the patient had hematemesis.
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Internal hernia with gangrenous bowel
B. Exploratory laparotomy
The key to the correct diagnosis in this case is a patient with unstable vital signs, an acute abdomen, hematemesis, and CT findings of internal hernia with mesenteric vascular compromise. Operative findings revealed an internal hernia through the Petersen space, with tight twisting of the bowel resulting in infarction and gangrene in the mid-Roux limb and in the ileum. She required vasopressive drugs to maintain blood pressure while in the operating room. Because of her hemodynamic instability, after resection of the necrotic bowel her intestines were left discontinuous and the abdomen open. She was returned to the operating room 36 hours later and her intestines were reconnected.
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Corresponding Author: Sameer B. Murali, MD, MSHS, 17296 Slover Ave, Fontana, CA 92337 (Sameer.B.Murali@kp.org).
Published Online: February 20, 2019. doi:10.1001/jama.2017.18946
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient for providing permission to share her information.
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