Obesity is a global epidemic8. Surgery has proven to be the most effective treatment for morbid obesity8. The estimated prevalence of non-alcoholic fatty liver disease in obese is three times higher than in the general population8. It progresses to non-alcoholic steatohepatitis in up to 42% of cases, which has become a growing indication for liver transplantation (LT)8. Bariatric surgery in patients with cirrhosis prior to LT may improve access in the waiting list. The number of patients on the waiting list for transplantation having undergone bariatric surgery will grow, with a potential increase in the rate complications. Peptic ulcer (PU) perforation is one of them. Following Roux-en-Y gastric bypass (RYGBP), the modified anatomy and physiology are a risk factor for peptic ulceration of an excluded stomach. Furthermore, LT carries specific risk factors for PU. Diagnosis in the gastric remnant can be challenging due to the absence of endoscopic access.
A 45-year-old woman with a history of open Fobi-Capella RYGBP was diagnosed with primary biliary cirrhosis and listed for LT. Bariatric surgery was carried out seven years before, followed by an emergency reintervention for obstruction of the jejunojejunostomy. Hepatopathy was diagnosed at 41 years of age. The patient presented Ig G antibodies for cytomegalovirus and a negative viral DNA detection by quantitative PCR. There were no other relevant comorbidities.
She was admitted to the emergency department with melena and hematochezia. Physical examination revealed hypotension, paleness, icterus and a pain-free abdomen without ascites. Her Model for End-Stage Liver Disease score was 33. The patient did not smoke, consume alcohol to excess or use nonsteroidal anti-inflammatory drugs, acetylsalicylic acid, or proton pump inhibitors. The Helicobacter pylori (HP) status was unknown, nor it was investigated. The patient was clinically managed with intravenous crystalloids, blood borne products transfusion, PPI and ciprofloxacin. The upper endoscopy was negative and the abdominal Doppler ultrasound showed signs of portal hypertension with patent hepatic vessels. Six days after admission, deceased donor LT was carried out without perioperative complications.
The postoperative immunosuppression regimen consisted of prednisone, tacrolimus and mycophenolate sodium. The prophylactic antibiotics consisted of amikacin and ampicillin until postoperative day (POD) 2 and ivermectin on PODs 2 and 3; sulfamethoxazole was introduced on POD 8. Acetylsalicylic acid and prophylactic low molecular weight heparin were suspended from POD 3 to POD 7 because of anemization without signs of bleeding. Low molecular weight heparin was reintroduced at therapeutic dose because of the thrombosis of a branch of the right portal vein. On POD 7 hepatic biopsy was performed due to elevation in liver enzymes. Moderate acute cellular rejection was diagnosed and treated with pulse therapy of methylprednisolone. Proton pump inhibitors were administered throughout the hospitalization. On POD 14 the patient developed an acute abdomen. An abdominal computed tomography scan with intravenous contrast showed a pneumoperitoneum with foci of free air next to the stomach and free abdominal fluid in small quantity (Figure 1).
An emergency laparotomy was performed and a perforated ulcer of the body of the excluded stomach was found and repaired by simple closure. The ulcer was not resected for pathological examination. On POD 16 routine quantitative PCR for cytomegalovirus DNA was positive (41UI/ml 1,62 log (UI/ml)), but did not require antiviral therapy nor reduction in the immunosuppressive regimen. Prophylactic unfractioned heparin was administered from POD 16. Culture of the abdominal liquid collected intraoperatively showed positive for extended spectrum beta-lactamase producing Klebsiella pneumoniae and Enterococus faecium. Antibiotic treatment consisted of vancomycin, meropenem and fluconazol. The patient was discharged on POD 26 with immunosuppressors, sulfamethoxazole, proton pump inhibitors and prophylactic low molecular weight heparin, the latter being discontinued ten days after this.
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