Can pleuritic substernal chest pain occur as a result of bariatric treatment, including bariatric surgery (Roux‑en‑Y gastric bypass, sleeve gastrectomy, adjustable gastric banding) or medical therapies (phentermine, liraglutide, semaglutide)?

Can Pleuritic Substernal Chest Pain Occur After Bariatric Treatment?

Yes, pleuritic substernal chest pain can occur as a complication of bariatric surgery and represents a potentially serious warning sign that requires urgent evaluation. While the available evidence does not specifically address medical bariatric therapies (phentermine, liraglutide, semaglutide) causing pleuritic chest pain, surgical bariatric procedures are well-documented to produce this symptom as part of their complication profile.

Pleuritic Chest Pain as a Presenting Symptom

Pleuritic chest pain after bariatric surgery should raise immediate concern for pulmonary embolism (PE), anastomotic leak, or other serious complications. 1

• A documented case report describes a patient who developed new-onset shortness of breath and pleuritic chest pain post-laparoscopic gastric bypass surgery, initially diagnosed as pulmonary embolus but ultimately found to have hospital-acquired pneumonia 1
• This case illustrates the diagnostic difficulty in bariatric patients presenting with pleuritic chest pain, as multiple serious conditions can produce similar symptoms 1
• Bariatric surgery patients are at high risk for venous thromboembolism, making PE a critical differential diagnosis when pleuritic chest pain develops 1

Common Presentations of Chest and Abdominal Pain After Bariatric Surgery

Abdominal pain is the most common reason bariatric patients present to emergency departments, occurring in 15-30% of patients within three years of surgery, particularly after Roux-en-Y gastric bypass. 2

• The most common symptoms identified in diagnosing anastomotic leak after sleeve gastrectomy include abdominal pain, tachycardia, and fever 2
• Clinical signs can be atypical and insidious, often resulting in delayed management due to inconclusive findings 2
• Tachycardia is considered the main alarming sign in the early postoperative period 2

Specific High-Risk Complications That May Present With Chest Pain

Pulmonary Embolism

• Bariatric surgery patients are at elevated risk for deep vein thrombosis and pulmonary embolism 2, 1
• Perioperative complications after gastric bypass include deep vein thrombosis/pulmonary embolism in approximately 0.4% of cases 2
• Type 1 respiratory failure may accompany pleuritic chest pain in these patients 1

Anastomotic Leak

• Anastomotic leaks can present with chest or upper abdominal pain, particularly when involving the gastroesophageal junction in sleeve gastrectomy 2
• Late postoperative complications may manifest with hemodynamic instability, respiratory failure, or renal dysfunction in the presence of sepsis 2

Rare but Serious: Gastropulmonary Fistula

• Gastropulmonary fistulas, though rare, represent an important complication of Roux-en-Y gastric bypass that can cause chest symptoms 3
• This serious complication has been reported even after uneventful laparoscopic gastric bypass surgery 3

Critical Diagnostic Approach

When a bariatric surgery patient presents with pleuritic substernal chest pain, immediate diagnostic work-up should include:

• Vital signs assessment focusing on tachycardia (≥110 bpm), fever (≥38°C), tachypnea, and hypotension 2
• CT imaging with consideration for CT pulmonary angiogram if PE is suspected 1
• Laboratory evaluation including complete blood count, comprehensive metabolic panel, and lactate levels 2
• Early surgical consultation is essential, as laboratory studies may not reveal major pathology even in the presence of serious complications 2

Key Clinical Pitfalls to Avoid

The altered anatomy and physiology after bariatric surgery creates diagnostic challenges that can lead to delayed recognition of serious complications. 2, 4

• Physical examination findings may be atypical or insidious 2
• White blood count and serum lactate levels are frequently normal even with internal hernias or other serious complications 2
• Emergency physicians and acute care surgeons must maintain a high index of suspicion, as up to 25% of bariatric patients return to the emergency department within the first two years 5
• The World Society of Emergency Surgery guidelines recommend prompt diagnostic work-up and laparoscopic surgical exploration in patients with previous bariatric surgery presenting with persistent symptoms associated with fever, tachycardia, and tachypnea 2

Regarding Medical Bariatric Therapies

The available evidence does not document pleuritic substernal chest pain as a recognized complication of medical weight loss therapies including phentermine, liraglutide, or semaglutide 2. These medications have different adverse event profiles focused primarily on gastrointestinal symptoms, and chest pain related to these agents would more likely represent cardiovascular effects rather than pleuritic pain.