What is the best course of action for a patient with a history of sliding hiatal hernia status post (after) fundoplication surgery, who presents with abdominal pain and tenderness after forceful vomiting, given their surgical history and current symptoms of flu-like illness, diarrhea, and myalgias (muscle pains)?

Immediate Emergency Department Evaluation Required

This patient requires urgent emergency department evaluation with comprehensive laboratory testing, imaging, and surgical consultation to rule out fundoplication disruption or other serious post-surgical complications. The combination of forceful vomiting, persistent abdominal pain, and prior fundoplication surgery creates significant risk for anatomic failure that demands prompt assessment. 1, 2

Critical Warning Signs Present

This patient exhibits several concerning features that mandate urgent evaluation:

• Persistent vomiting and abdominal pain are alarming clinical signs indicating high probability of complications including internal hernia, volvulus, gastrointestinal stenosis, or intestinal ischemia after upper gastrointestinal surgery 1

• Forceful vomiting after fundoplication is a known precipitating factor for anatomic fundoplication failure, particularly wrap disruption or intrathoracic migration 3

• Pain severity requiring crying followed by improvement with immobility suggests potential mechanical complication rather than simple gastroenteritis 4

• Three days without oral intake increases risk of dehydration and metabolic derangement while potentially masking evolving complications 1

Immediate Diagnostic Workup Required

Vital Signs Assessment

• Monitor for tachycardia ≥110 bpm, which is the single most sensitive early warning sign of surgical complications, even when other vital signs remain stable 2, 5
• Check for fever ≥38°C, hypotension, tachypnea, or decreased urine output as these indicate potential septic complications 1
• Note that the absence of fever does NOT rule out serious complications, as many post-surgical emergencies present without fever initially 5

Laboratory Testing

Obtain comprehensive laboratory evaluation including: 1

• Complete blood count
• Serum electrolytes and renal function
• C-reactive protein (CRP) - elevated levels predict both early and late postoperative complications 1
• Serum lactate levels
• Liver function tests
• Blood gas analysis if clinically indicated

Important caveat: Normal laboratory values do not exclude fundoplication failure or other mechanical complications, as white blood count was normal in 68.75% of cases with internal herniation, and lactate was normal in 90% 1

Imaging Studies

• Contrast-enhanced CT abdomen/pelvis with IV contrast should be obtained promptly, offering 88-94% sensitivity for post-surgical complications 5
• Upper GI series may be considered to assess fundoplication integrity and identify herniation of abdominal contents through the esophageal hiatus 6, 4

Specific Complications to Exclude

Anatomic Fundoplication Failure

• Occurs in approximately 7% of patients after laparoscopic fundoplication 3
• New-onset postoperative epigastric or substernal chest pain frequently heralds fundoplication failure 3
• Intrathoracic migration of the wrap with or without disruption is the most common pattern 3
• Early postoperative vomiting (even one year later) is a correlated risk factor 3
• Presents with vague but persistent abdominal pain, often associated with nausea and vomiting 4

Hiatal Hernia Recurrence

• Can occur through the esophageal hiatus after fundoplication, involving stomach and potentially transverse colon 6, 4
• Symptoms include persistent abdominal pain (typically >48 hours), nausea, and vomiting 4
• Diagnosis confirmed with upper GI series showing proximal stomach displacement 4

Surgical Consultation

Early involvement of the original bariatric/foregut surgeon optimizes clinical outcomes 1

If the original surgeon is unavailable, consult general surgery or acute care surgery immediately because: 1

• Clinical presentation can be non-specific and insidious after fundoplication
• Delayed management due to inconclusive findings leads to poor outcomes and high morbidity
• Diagnostic laparoscopy has higher sensitivity and specificity than radiological assessment when clinical suspicion remains high 5

Management Algorithm

If Hemodynamically Stable with Mild Symptoms:

• Admit for observation with hourly vital sign monitoring 5
• NPO status with IV fluid resuscitation for dehydration 1
• Obtain laboratory testing and imaging as outlined above 1
• Maintain low threshold for surgical exploration if pain persists or worsens 5

If Concerning Clinical Findings Develop:

Do not delay surgical exploration if the patient develops: 1, 2

• Persistent abdominal pain with peritoneal signs (guarding, rigidity, rebound tenderness)
• Tachycardia ≥110 bpm, especially if persistent
• Fever, hypotension, or respiratory distress
• Abdominal distention suggesting obstruction

If Peritonitis or Hemodynamic Instability:

• Surgical exploration is mandatory without delay 1, 2
• Laparoscopic exploration should be attempted first if hemodynamically stable and expertise available 2
• Convert to open laparotomy if hemodynamic instability develops or severe peritonitis encountered 2

Critical Pitfalls to Avoid

• Never dismiss symptoms as "normal after vomiting" in a patient with prior fundoplication - anatomic failure must be excluded 3, 4
• Do not rely on absence of fever to rule out serious complications 5
• Do not delay diagnostic workup waiting for symptoms to resolve, as delayed diagnosis increases morbidity 1
• Tachycardia should never be dismissed as "normal postoperative" when accompanied by persistent abdominal pain 5
• Normal laboratory values do not exclude mechanical complications like wrap disruption or herniation 1
• Delaying surgery for imaging confirmation when peritonitis is clinically evident increases mortality 2

Concurrent Gastroenteritis Consideration

While flu-like symptoms with diarrhea suggest viral gastroenteritis, this does NOT exclude surgical complications:

• The forceful vomiting from gastroenteritis may have precipitated fundoplication failure 3
• Gastroenteritis symptoms can mask evolving surgical complications 1
• Both conditions may coexist, requiring treatment of both the infection and any mechanical complication