Differential Diagnosis for 29F Post-Lap Cholecystectomy
Single Most Likely Diagnosis
- Bile duct injury or leak: This is a common complication after laparoscopic cholecystectomy, and the presentation of bilious vomiting after melena and a clear CT angio suggests a possible bile duct injury. The recent surgery and readmission for melena, followed by bilious vomiting, point towards a complication related to the biliary system.
Other Likely Diagnoses
- Gastrointestinal bleeding from an ulcer or erosion: The initial presentation of melena, which is black, tarry stool indicating upper gastrointestinal bleeding, followed by PRBC and iron infusion, suggests that there might be an ongoing or recurrent gastrointestinal bleed. The bilious vomiting could be secondary to the bleeding or to the treatment.
- Post-operative ileus or bowel obstruction: Although less likely given the presence of bilious vomiting, these conditions can occur post-operatively and could explain some of the symptoms. However, the clear CT angio makes bowel obstruction less likely.
Do Not Miss Diagnoses
- Hemobilia: This is a condition where there is bleeding into the biliary tree, which could explain both the melena (if the blood enters the intestine) and the bilious vomiting. It's a serious condition that requires prompt intervention.
- Pulmonary embolism: Although not directly related to the gastrointestinal symptoms, pulmonary embolism is a significant risk in post-operative patients, especially those who have been immobile or have had recent surgery. It's crucial to consider this diagnosis due to its high mortality rate if missed.
Rare Diagnoses
- Ampullary injury or rupture: This could lead to similar symptoms but is less common compared to bile duct injuries.
- Pancreatico-biliary fistula: A rare complication that could occur after cholecystectomy, leading to the symptoms described.
- Gallstone ileus: Although rare, it could occur if a gallstone erodes into the intestine, causing an obstruction. However, this would more likely present with symptoms of obstruction rather than bilious vomiting alone.