Workup for Post-Bariatric Surgery Patient with Upper Abdominal Pain and Dysphagia
The initial outpatient GI workup for this 42-year-old male with history of bariatric surgery presenting with longstanding upper abdominal pain, dysphagia to solids and liquids, and regurgitation should begin with an upper endoscopy followed by a barium esophagram. 1
Initial Diagnostic Approach
1. Upper Endoscopy (First-line)
- Essential for direct visualization of:
- Anastomotic strictures or stenosis
- Marginal ulcers
- Evidence of obstruction
- Internal hernias
- Fistula formation
- Pouch dilation
- Gastric remnant pathology
Upper endoscopy is particularly valuable as it allows for both diagnosis and potential therapeutic intervention in the same session 1. This is especially important for patients with dysphagia after bariatric surgery, as strictures can be identified and potentially dilated during the procedure 1.
2. Barium Esophagram (Second-line)
- Provides complementary information about:
- Anatomic abnormalities
- Functional assessment of swallowing
- Presence and size of hiatal hernia
- Strictures or narrowing
- Gastroesophageal reflux
- Pouch size and emptying
A biphasic esophagram is recommended as it combines both single and double-contrast techniques, achieving a higher sensitivity (88%) for detecting esophagitis and structural abnormalities than either technique alone 1.
Additional Testing Based on Initial Findings
3. CT Abdomen and Pelvis with IV Contrast
- Indicated if:
- Endoscopy and esophagram are inconclusive
- Suspicion of small bowel obstruction
- Concern for internal hernia
- Evaluation of extraluminal complications
CT imaging is particularly valuable for evaluating potential complications like internal hernias, which are common causes of small bowel obstruction after Roux-en-Y gastric bypass 1.
4. Esophageal Manometry
- Consider if:
- Dysphagia persists despite normal endoscopic findings
- Suspicion of motility disorder
- Evaluation of lower esophageal sphincter function
Manometry can help identify motility disorders that may develop after bariatric surgery, particularly in patients with persistent dysphagia 2.
5. 24-hour pH Monitoring
- Consider if:
- Symptoms suggest GERD
- Endoscopy shows evidence of reflux esophagitis
- Persistent symptoms despite therapy
Important Considerations
Post-Bariatric Surgery Complications to Consider
- Anastomotic strictures: Common cause of dysphagia after RYGB
- Internal hernias: Can cause intermittent or persistent abdominal pain 1
- Marginal ulcers: May cause epigastric pain and dysphagia
- Candy cane syndrome: Redundant blind limb at gastrojejunostomy causing symptoms
- Gastric pouch dilation: Can lead to regurgitation
- Sleeve stenosis: Can occur after sleeve gastrectomy causing dysphagia 3
- Fistula formation: Between gastric pouch and excluded stomach
Alarm Features Requiring Urgent Evaluation
- Weight loss
- Persistent vomiting
- Inability to maintain hydration
- Severe, unrelenting pain
- Signs of obstruction
Pitfalls to Avoid
Delayed diagnosis: Patients with post-bariatric surgery complications should be evaluated promptly, as complications like internal hernias can lead to bowel necrosis if not treated quickly 3.
Inadequate imaging: Standard endoscopy may not visualize the excluded stomach and duodenum in RYGB patients; specialized techniques may be needed 1.
Missing nutritional deficiencies: Always assess for vitamin B12, iron, calcium, and vitamin D deficiencies, which can contribute to symptoms 4.
Overlooking functional disorders: Not all symptoms are due to anatomical abnormalities; functional disorders can coexist 1.
By following this systematic approach, the underlying cause of this patient's upper abdominal pain, dysphagia, and regurgitation can be identified and appropriate treatment initiated to improve their quality of life.