Differential Diagnosis for Postgastrectomy Patient

Single Most Likely Diagnosis

• Dudenal blow out: This condition, also known as duodenal stump leak, is a serious complication that can occur after gastric surgery, especially if the duodenal stump is not closed properly. The presentation of abdominal pain, tenderness, distension, and elevated white blood cell count (WBC) on day 4 post-operatively, after the removal of drains and initiation of oral feeding, is consistent with a duodenal blowout. The stable vital signs do not rule out this condition, as patients can initially present with stable vitals before deteriorating.

Other Likely Diagnoses

• Jujenojejunial leak: Although less common than duodenal stump leaks, anastomotic leaks at the jejunojejunostomy site can occur, especially if there was tension on the anastomosis or if the patient has underlying conditions that impair healing. Symptoms would be similar to those of a duodenal blowout, including abdominal pain, tenderness, and elevated WBC.
• Esophagojejunial leak: This is another potential site for an anastomotic leak following gastrectomy, particularly if the esophagojejunostomy was under tension or if there were technical difficulties during the procedure. However, leaks at this site might also present with symptoms such as dysphagia or coughing, in addition to abdominal symptoms.

Do Not Miss Diagnoses

• Intra-abdominal abscess: While not necessarily a leak, an intra-abdominal abscess can present with similar symptoms, including abdominal pain, tenderness, distension, and elevated WBC. It is crucial to consider this diagnosis, as untreated abscesses can lead to sepsis and death.
• Bowel obstruction: Early bowel obstruction can occur post-operatively and present with abdominal distension, pain, and tenderness. Although the vital signs are stable, missing a bowel obstruction could lead to severe consequences, including bowel ischemia.

Rare Diagnoses

• Pancreatic fistula: Although less common, a pancreatic fistula could occur, especially if the pancreas was manipulated or injured during the surgery. This would typically present with abdominal pain and elevated amylase levels in the drain fluid, if present.
• Hematoma or bleeding: A post-operative hematoma or bleeding could cause abdominal pain and distension. While less likely given the stable vital signs, it is a diagnosis that should be considered, especially if there is a drop in hemoglobin or hemodynamic instability develops.