A53-52 A Unique Case of a Retroperitoneal Hemorrhage

Abstract Introduction Within the United States, adult obesity is associated with many medical conditions and complications with prevalence of 40% without a significant difference among genders.1,2 Moreover, the introduction of bariatric surgery has provided a surgical intervention for weight loss in patients. Amongst the various Bariatric surgery, Roux-en-Y Gastric Bypass (RYGB) is a very common approach over the last decade.3 Although is generally considered safe, RYGB is not free of postoperative complications. In this case report, we present a patient with a biliary limb hemorrhage from an RYGB nearly 30 years prior. Case Presentation A 76-year-old man with a medical history including atrial fibrillation, COPD, multivessel coronary artery disease (CAD), hypertension and obesity status post Roux-en-Y gastric bypass (RYGB, 1994) presented from a satellite emergency department with fever, diaphoresis and dyspnea. Family reported three days of wheezing and profuse diarrhea and was subsequently transferred to the university hospital for persistent dyspnea. On admission, his primary diagnosis was multivessel CAD from a cardiac catheterization and was being medically evaluted for coronary artery bypass grafting (CABG) including initiation of anticoagulation. During hospitalization the patient became presyncopal upon standing, reporting dyspnea, abdominal pain, and chest discomfort. Later developing hematochezia, prompting escalation to the intensive care unit. Hemorrhagic shock was determined, necessitating transfusion followed by computed tomography (CT) angiogram demonstrating a gastrointestinal bleeding localized to the biliary limb. Given these findings, embolization of the gastroduodenal artery was performed to achieve hemostasis. Discussion The incidence of late bleeding account for 1%, associated with peptic ulcer disease or ischemia secondary to chronic irritation or use of ulcerogenic agents and anticoagulants.5 Management is guided by hemodynamic stability with endoscopy being the cornerstone of evaluation amongst stable patients. Whereas unstable patients require immediate resuscitation and supportive care before invasive procedures. The diagnostic workup includes endoscopic evaluation and/or CT imaging to determine intraluminal vs intraabdominal etiology. Our patient’s use of anticoagulation while undergoing CABG evaluation adds layers of complexity in both diagnosis and management. While necessary to prevent thromboembolic events, anticoagulation increases the risk of GI bleeding in those with a history of ulcers or gastric surgery. This highlights the delicate balance between preventing cardiac related events and mitigating bleeding risk. Moreover, presentation of melena, presyncope, and epigastric discomfort necessitates a broad differential. Often these symptoms are mimickers of cardiac pathology, thus emphasizing the need for careful clinical correlation and multidisciplinary coordination between critical care, interventional radiology and cardiology teams. This abstract is funded by: None