Differential Diagnosis for Post-Gastrectomy Patient with Elevated WBCs

The patient's presentation of elevated WBCs, normal NGT, 150 ml of drain output, and a soft, lax abdomen 3 days after undergoing gastrectomy with Roux en Y gastrojejunostomy suggests an infectious or inflammatory process. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • B. Jejunal leakage: This is a common complication following Roux-en-Y gastrojejunostomy. The elevated WBC count suggests an infectious process, and jejunal leakage can lead to peritonitis or an abscess, which would explain the elevated white blood cell count. The presence of 150 ml of drain output could be consistent with a small leak, especially if the fluid is not clearly enteric in nature.

• Other Likely Diagnoses

  • D. Oesophagojejunal leak: Although less common than jejunal leakage, an oesophagojejunal leak could also explain the elevated WBCs due to infection. However, the absence of specific symptoms like coughing or chest pain when the NGT is checked makes this slightly less likely.
  • A. Duodenal stump blow out: This is a serious complication but might be less likely given the soft and lax abdomen. Duodenal stump leakage often presents with more dramatic signs of peritonitis or sepsis.

• Do Not Miss Diagnoses

  • A. Duodenal stump blow out: Despite being potentially less likely based on the physical exam, a duodenal stump blowout is a life-threatening condition that requires immediate intervention. Missing this diagnosis could be fatal.
  • D. Oesophagojejunal leak: Similar to duodenal stump blowout, an oesophagojejunal leak can lead to severe consequences, including mediastinitis or peritonitis, if not promptly addressed.

• Rare Diagnoses

  • C. Jejunojejunostomy: Issues at the jejunojejunostomy site, such as a leak or obstruction, are less common causes of elevated WBCs in this context but should be considered if other explanations are ruled out. The clinical presentation would likely include signs of obstruction or leakage, which are not prominently featured in the scenario provided.
  • Other infectious complications: Such as pneumonia, urinary tract infections, or line infections, which could also cause elevated WBCs but are less directly related to the surgical procedure itself.