38. Internal Hernias: No Bulge, No Hernia?

Andrew D. Chou¹ and Colin G. Kaide¹

(1)

Department of Emergency Medicine, Wexner Medical Center at The Ohio State University, Columbus, OH, USA

Andrew D. Chou

Email: Andrew.Chou@osumc.edu

Keywords

Internal herniaGastric bypassRoux-en-Y

Case 1

Abdominal Pain after Roux-En-Y

Pertinent History

A 47-year-old female presented to the emergency department (ED) complaining of abdominal pain, nausea, and vomiting. The pain is located in the epigastric area, and symptoms have been intermittent but have progressively worsened over the past 3 days to the point that she is now unable to tolerate any oral intake, even liquids. She has not had any fevers. She normally has bowel movements every day but thinks that she has not had one in 2 days. She is not passing flatus. She has not had any diarrhea and denies any sick contacts.

Pertinent Physical Exam

Except as noted below, the findings of the complete physical exam are within normal limits.
Vitals: Temperature 98.7, HR 115, BP 143/86, RR 18, O2 saturation 99% on room air
HEENT: Dry mucous membranes
CV: Mild tachycardia
Abdomen: Mild guarding with moderate associated tenderness in the epigastric area. No rebound tenderness

PMH

Morbid obesity, hypertension, hyperlipidemia, type 2 diabetes, GERD. Roux-en-Y gastric bypass performed 8 years ago

SH

Ten pack-year previous smoker, social alcohol drinker, denies illicit drug use

FH

Hypertension, diabetes, hyperlipidemia, coronary artery disease on both sides of the family

Pertinent Test Results

Test	Result	Units	Normal Range
WBC	13.7	K/uL	3.8–11.0 10³/mm³
Hgb	12	g/dL	(Male) 14–18 g/dL (Female) 11–16 g/dL
Platelets	286	K/uL	140–450 K/uL
Sodium	137	mEq/L	135–148 mEq/L
Potassium	3.6	mEq/L	3.5–5.5 mEq/L
Chloride	94	mEq/L	96–112 mEq/L
Bicarbonate	22	mEq/L	21–34 mEq/L
BUN	18	mg/dL	6–23 mg/dL
Creatinine	1.4	mg/dL	0.6–1.5 mg/dL
Glucose	146	mg/dL	65–99 mg/dL
Lipase	47	U/L	12–70
Troponin	<0.01	ng/dl	<0.04
Lactate	3.5	mmol/L	<2.0