It’s nearing the end of a busy shift, and the last patient you pick up is a 45-year-old female with nausea and vomiting – a rather uninteresting complaint, at first glance. However, after speaking with her, you learn that her symptoms, initially intermittent, have been increasing over the past 4 weeks to the point where solids and liquids “just won’t go down.” She also reports that she has lost more than 50 pounds since undergoing laparoscopic adjustable gastric band placement 9 months prior.
Explore This IssueACEP News: Vol 30 – No 09 – September 2011
On physical exam she is tachycardic at 110 bpm, and afebrile with a normal blood pressure and oxygen saturation. She is in visible discomfort and the nurse informs you that she has vomited twice since being brought back from triage. The physical examination is remarkable for a soft abdomen with slightly increased bowel sounds and mild tenderness in the left upper quadrant without guarding or rebound.
Laboratory evaluation reveals a potassium of 3.3 mEq/L, but the remainder of the electrolytes, liver function, renal function, complete blood count, and lipase are unremarkable. A two-view abdominal series, ordered out of concern for possible small bowel obstruction, is read by the radiologist as “negative for obstruction” without other acute findings. Following IV fluids and antiemetics, the patient was feeling much improved. She was discharged home with instructions to call her bariatric surgeon the next morning to arrange a follow-up visit.
Dx: Slipped Gastric Band
The following morning the patient called the bariatric surgery clinic with ongoing severe vomiting and was told to return for an upper gastrointestinal series. The UGI study demonstrated an aberrantly positioned gastric band without passage of contrast into the duodenum (Fig. 1) – findings very concerning for gastric outlet obstruction. The patient was taken urgently to the OR for exploratory laparoscopy and explantation of the gastric band.
While the diagnosis of slipped gastric band was unfortunately overlooked on the patient’s first emergency department visit, there are a few radiographic clues to help determine if your next patient with a gastric band and obstructive symptoms has an incorrectly positioned band that could be causing problems.
Correct position on AP radiograph (Fig. 2): The gastric band appears as a discoid opacity as you view the band on its side. The gastric band should be positioned in the left upper quadrant of the abdomen at an acute angle to the long axis of the spine, ranging anywhere from 4 to 58 degrees.1