From the Guidelines
Management of severe abdominal pain after bariatric surgery requires prompt evaluation and a systematic approach, with a focus on early diagnosis and treatment to reduce morbidity and mortality rates, as emphasized by the OBA guidelines 1. The initial management should include:
- IV fluid resuscitation
- Pain control with medications like hydromorphone 0.5-1mg IV every 4 hours or fentanyl 25-50mcg IV every 1-2 hours
- Antiemetics such as ondansetron 4mg IV every 6 hours Urgent laboratory tests (CBC, CMP, lipase, lactate) and imaging (CT scan with oral and IV contrast if tolerated) are essential to rule out serious complications like anastomotic leak, internal hernia, or bowel obstruction, as highlighted in the study by De Simone et al. 1. Surgical consultation should be obtained immediately, as these complications often require reoperation, and early intervention is critical to prevent sepsis and increased mortality, as noted in the study by Torres-Villalobos et al. 1. While awaiting definitive diagnosis, the patient should remain NPO, receive adequate analgesia, and undergo close monitoring of vital signs. For non-surgical causes of pain, such as marginal ulcers, appropriate treatment includes proton pump inhibitors (esomeprazole 40mg IV twice daily), sucralfate 1g orally four times daily if able to tolerate oral medications, and avoidance of NSAIDs, as recommended in the study by Agaba et al. 1. Patients should be monitored for signs of improvement or deterioration, with surgical exploration considered if pain persists or worsens despite conservative management, as emphasized in the study by Geubbels et al. 1. The use of imaging studies, such as CT scans, is crucial in diagnosing complications after bariatric surgery, and the interpretation of these studies requires knowledge of the new anatomical landmarks and potential complications, as highlighted in the study by Alharbi et al. 1. In pregnant women with a history of bariatric surgery, US and MRI are preferred to assess acute abdominal pain, with the aim of limiting radiation exposure to the embryo or fetus, as noted in the study by Dave et al. 1. The key to successful management of severe abdominal pain after bariatric surgery is a multidisciplinary approach, with close collaboration between emergency surgeons, radiologists, endoscopists, and anesthesiologists, as emphasized by the OBA guidelines 1.
From the Research
Management of Severe Abdominal Pain After Bariatric Surgery
- Severe abdominal pain is a common complication after bariatric surgery, with a prevalence of 3-61% of subjects with health care contacts or readmissions 1-5 years after surgery 2
- The causes of abdominal pain after bariatric surgery can be behavioral, anatomical, and/or functional disorders 2
- Persistent opioid use is associated with severe pain symptoms and is most prevalent among subjects with a lower socioeconomic status 2
- Alteration of absorption and distribution after bariatric surgery may impact opioid effects and increase the risk of adverse events and development of addiction 2
Treatment Options
- Intravenous acetaminophen (IV APAP) can be used to optimize multimodal analgesia with opioids in postoperative bariatric patients, reducing postoperative opioid use and hospital length of stay 3
- Abdominal wall infiltrations using an anesthetic agent or a neurectomy can be successful in treating abdominal wall pain associated with Anterior Cutaneous Nerve Entrapment Syndrome (ACNES) after bariatric surgery 4
- Intravenous patient-controlled analgesia (IV-PCA) can be used to manage pain after laparoscopic bariatric surgery, but inadequate pain control at PACU discharge can be a risk factor for moderate to severe pain during the first 24 hours postoperatively 5
Risk Factors
- Revisional surgery is a significant predictor for unexplained abdominal pain after laparoscopic bariatric surgery 6
- Young age, female sex, postoperative administration of NSAIDs, first pain score greater than 3 on arrival at the PACU, and inadequate pain control at PACU discharge are associated with moderate to severe pain during the first 24 hours after laparoscopic bariatric surgery 5
- Inadequate pain control at PACU discharge is the only independent risk factor for moderate to severe pain during the first 24 hours postoperatively 5