A 44-Year-Old Woman with Dyspnea and Hemoptysis in the Setting of Remote Bariatric Surgery

Case Presentation

A 44-year-old woman was transferred to the ED from an outside hospital because of hemoptysis and concern for left-sided pulmonary infiltrate with associated pleural effusion. The patient presented to this outside hospital multiple times over the past 3 months because of left-sided shoulder pain, diffuse myalgias, and supraventricular tachycardia. On her third visit, she was found to have a left-sided pleural effusion and underwent diagnostic and therapeutic thoracentesis; 1.5 L of fluid was removed. Fluid studies reportedly demonstrated an exudative pleural effusion with negative bacterial cultures and no evidence of neoplastic process. The patient was referred to the Rheumatology Department by the outside hospital for suspected underlying autoimmune process. In the months leading up to her current presentation, the patient had been prescribed one prednisone burst and two prednisone tapers. She was then placed on a regimen of 10 mg prednisone daily and 200 mg hydroxychloroquine bid by her primary care doctor. This was tapered by the Rheumatology Department such that the patient was on 7.5 mg of prednisone daily on arrival to this ED. Rheumatologic workup until this point revealed only low titer (1:80) positive antinuclear antibody. Prior to these ED visits, the patient had been otherwise healthy with only a history of a Roux-en-Y gastric bypass 17 years earlier. Aside from recent daily low-dose prednisone use, the patient did not have other preexisting immune compromise or risk factors for aspiration such as seizure disorder, chronic alcohol use, or cognitive impairment. Before her transfer, the patient experienced foul-smelling, maroon-colored hemoptysis as well as anemia that required a higher level of care. On arrival to the ED, she was in acute hypoxic respiratory failure. The patient was intubated emergently and was admitted to the medical critical care unit for further treatment.

Physical Examination Findings

On presentation, the patient’s vital signs revealed a temperature of 36.8 °C, a heart rate of 161 beats/min, BP of 137/61 mm Hg, and a respiratory rate of 65 respirations per minute with oxygen saturation of 97% on 6 L of oxygen by nasal cannula. Before intubation, the patient was noted to have conversational dyspnea and was actively coughing up maroon-colored sputum. She was alert and able to answer questions. Dry, brown blood was observed in the oropharynx. She denied any chest or abdominal pain. Diminished breath sounds were noted bilaterally without wheezes or crackles. No rashes, oral lesions, or obvious joint swelling or deformity was noted. The remainder of her physical examination was unremarkable.

Diagnostic Studies

Complete blood count demonstrated a WBC count of 16,300 cells/μL and a hemoglobin level of 9.4 g/dL after 2 units of blood transfusion at the outside hospital. Creatinine was 1.00 mg/dL. Arterial blood gas revealed a pH of 7.24, Pco₂ of 33 mm Hg, Po₂ of 140 mm Hg, and bicarbonate of 14 mEq/L while on 6 L nasal cannula. Lactate was elevated to 2.7 mM. Chest x-ray showed a left-sided pulmonary infiltrate with associated pleural effusion (Fig 1). CT angiogram of the chest, abdomen, and pelvis was remarkable for a large multiloculated collection with irregular air pockets in the left lower lobe that measured 8.7 × 5.5 × 9.1 cm and dense consolidations in the periphery of both lower lobes (Figs 2, 3). These findings were suspicious for pulmonary abscess.

Figure 1.

One-view chest radiogram that was performed at the patient’s initial presentation. A left-sided pleural effusion with loculated component is seen.

Figure 2.

Coronal slice of CT angiogram of the chest in lung windows that was performed at the patient’s initial presentation shows left-sided pulmonary fluid collection with air pockets and stomach herniating through the diaphragm into the thoracic cavity.

Figure 3.

Axial slice of CT angiogram of the chest in lung windows from the patient’s initial presentation that further delineates the left-sided pulmonary fluid collection.

What is the diagnosis?

Diagnosis: Gastropulmonary fistula resulting in necrotizing pneumonia

Discussion

Bariatric surgery is a safe and effective surgical procedure for the treatment of morbid obesity and its metabolic comorbidities. Sleeve gastrectomy and Roux-en-Y gastric bypass are the two most commonly performed procedures. Between 2011 and 2017, the number of bariatric surgeries in the United States increased by 60%. Done via both open and laparoscopic approach, the Roux-en-Y gastric bypass procedure involves the creation of a small gastric pouch from the patient’s stomach and anastomosing it to the Roux limb of the jejunum. This allows food to bypass the proximal small bowel, limiting absorption. The most common early complications of the Roux-en-Y include anastomotic leak, ileus, obstruction, and hemorrhage. Common long-term complications include dumping syndrome, anastomotic stricture, late bowel obstruction, gallstone formation, and internal and hiatal hernia formation.

A potentially severe and morbid complication of bypass surgery is the gastropulmonary, or related gastrobronchial and gastropleural, fistula. This entity has been described in only a handful of case reports; because of its rarity, the exact incidence, morbidity, and mortality rate of this complication are unknown. In these reports, patients with this complication typically presented within a few months of their initial procedure. Proposed causes of fistula formation include subdiaphragmatic infection or inflammation that causes erosion into the intrathoracic cavity and left lower lobe of the lung and diaphragmatic herniation of the stomach with subsequent perforation.

This pathologic condition can be misdiagnosed easily as a primary pulmonary process because patients may not present until respiratory symptoms have developed, including cough, dyspnea, hemoptysis, and/or severe sepsis. However, an early symptom that may suggest this pathologic condition is shoulder pain. Shoulder pain could reflect referred pain from phrenic nerve irritation because of diaphragmatic compromise. In a patient with a history of intraabdominal surgery, the index of suspicion for potential sequelae of surgery should be high, and early CT imaging will aid in diagnosis.

Clinical Course

Because the patient had been transferred with the report that she had a suspected underlying rheumatologic disorder, she was given 1 g of methylprednisolone in addition to antibiotics while in the ED. The Rheumatology Department was consulted, and the physician felt the patient’s presentation was most consistent with a purely infectious process and recommended against further use of steroids. Although the patient’s condition had been afebrile and normotensive on arrival to the ED, it rapidly worsened, and she was admitted to the medical critical care unit for further treatment of septic shock.

The Thoracic Surgery Department was consulted in the ED to assist with evaluation of and source control for the patient’s suspected pulmonary abscess. They initially recommended bronchoscopy with cultures and consultation with interventional radiology for drain placement. However, bronchoscopy revealed gastric secretions in the patient’s airway, which prompted suspicion for a possible gastropulmonary fistula. At this point, outside hospital imaging was reviewed with the Radiology Department, at which point, a previously unrecognized gastropulmonary fistula was seen. Additional records were also obtained that outlined her surgical history. The General Surgery Department was consulted, given the diagnosis of gastropulmonary fistula after Roux-en-Y bypass, and operative intervention was pursued.

The patient was taken to the operating room as a joint case with both the Thoracic Surgery and General Surgery Departments. Intraoperatively, a small 3 × 3 cm defect was found in the left diaphragm through which the patient’s remnant stomach had herniated (Fig 4). An abscess cavity was found in this area, which communicated with the left lower lobe abscess cavity. The remnant stomach appeared to have been strangulated within the defect and subsequently perforated. This perforated segment was stapled and resected. Thoracoscopy was performed through the diaphragmatic defect: 400 mL of purulent material was removed (Figs 5, 6), and a transabdominal drain was placed. Notably, the necrotizing pneumonia had completely spared the pulmonary vasculature, which was plainly visible and intact on thoracoscopy and on contrast imaging. Postoperatively, the patient was transferred to the surgical critical care unit for further treatment.

Figure 4.

Intraoperative image shows the time at which the diaphragmatic defect, through which the stomach had herniated, was identified.

Figure 5.

Intraoperative image shows the time at which the diaphragmatic defect was opened, with immediate drainage of purulent fluid from the thoracic cavity.

Figure 6.

Intraoperative image in which the remnant stomach is held to the left of the defect by laparoscopic instruments and the opening, which connected the remnant stomach to the diaphragm, is visible.

Within 2 days, the patient was awake, extubated, and tolerating nutrition via gastrostomy tube. The patient was continued on broad-spectrum antibiotic coverage with vancomycin, cefepime, metronidazole, and fluconazole. Four days after the procedure, the patient was stable and was discharged from the critical care unit. Blood and body cultures ultimately had no growth; however, given the presence of purulent drainage intraoperatively, she was placed on a 4-week course of ertapenem and fluconazole after discharge, which subsequently deescalated to an additional 4-week course of moxifloxacin and fluconazole.

Clinical Pearls

• 1. A gastropulmonary fistula will present with pneumonia-like symptoms with associated pleural effusion or abscess; late presentation may involve respiratory failure and severe sepsis.
• 2. Hiatal and diaphragmatic herniation may place patients at greater risk of gastropulmonary fistula formation.
• 3. Referred shoulder pain from phrenic nerve irritation can be a sign of diaphragmatic compromise or irritation in a patient with a history of gastric bypass.
• 4. Clinicians should be vigilant for anchoring bias when taking over the care of another patient; in a case such as this, the authors would caution against administration of high-dose steroids before a confirmed diagnosis of either infectious or rheumatologic disease.