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.
  • C. Jejunojejunostomy leak: While less directly related to the initial surgery description focusing on gastrojejunostomy, any leak in the newly created intestinal connections could lead to infection and elevated WBCs. This diagnosis is critical not to miss due to its potential for severe complications.

• Rare Diagnoses

  • Intra-abdominal abscess not related to a specific anastomotic leak: While possible, this would be less directly related to the surgical procedure and more related to other post-surgical complications.
  • Pneumonia or other non-abdominal infections: These could explain elevated WBCs but would typically be accompanied by other symptoms such as fever, cough, or shortness of breath, which are not mentioned.

Each of these diagnoses should be considered in the context of the patient's overall clinical picture, with particular attention to the "Do Not Miss" category to ensure timely and appropriate management of potentially life-threatening conditions.