42 years old female with post intra-gastric balloon complication

1. Case presentation
by Dr Motaz & Muhanad Noureldin
SHO at AFHSR
MRCPI & MRCP UK
SAUDI ARABIA
SUPERVISED BY Consultant
Dr Adil

2. Sex : female
Age: 42 years old
C/O : Intractable vomiting/ 3 days
fatigability

3. HPI :-
A 42 years of old female medically free who
underwent gastric balloon 3 days ago,presented
to the A/E department, was complaining of
persistent vomiting since the operation
accompanied by extremely wasting.
No dysphagia, heart burn, hematemsis , but
epigastric pain which is localized not related to
food intake, no diarrhoea or melena or bleeding
per rectal.

4. •PMHx
No past medical history of significant.
No History of drug use or any drug allergy.
Underwent gastric balloon 3 days ago at private hospital
and it was uneventful. No blood transfusion.
FHx:-
Unremakable
Social Hx:-
A high socio-economic, Married , housewife, who lives
with her husband and 3 children. Neither Alcoholic
consumer nor smoker.

5. •O/E
Pt’s looked ill ,pale, dysponic , tachyponic R.R 25
cycle/min.
PR: 112 bpm regular large volume collapsing
BP :98/58 mmhg
Spo2 : 88% R.A
Abdominal examination : tenderness at the epigastrium
with no rigidty.
CVS : NAD
CHEST : NAD

6. •Investigations
Initially ECG and VBGS were requested
ECG showed ST depression on the inferior leads with T depression at the lateral leads.
VBGS
PH 7.56
Na 121
K 2.1
Po2 was normal
Pco2 was slightly elevated.
Labs on the ER as following:-
CBC
HB 13.2
MCV and MCH were low
PLTS and WBCS were normal.
Renal profile:
Showed kidney injury
BUN 11.8
Creatinine 137.4
Cardiac enzymes:
AST 168 H
CREATINE KINASE 8947.6 Very high
LDH 298 H
Troponin was normal
D-dimer was normal

11. Management:
Pt’s started on K+ correction, I.V fluids, I.V
mectlopromide 10mg , and oxygen supply.
Provisional diagnosis:
Rhabdomyolsis complicated AKI due to severe
vomiting.

12. Follow up
Oxygen was stopped as her Pco2 6.8 considering
this as a compensated metabolic alkalosis with a
hypoventilation mechanism adujsting.
CBC: HB dropped to 11.6 from 13
Renal profile : improved
LDH , CK, and AST were started to decrease
Pt’s showed clinical improvement ,yet she was
pale.
GI Bleeding was suspected.

15. Plan :
Admission to I.C.U
N.P.O
Vital signs monitoring
Electrolytes correction + I.V fluids
Metclopromide 10mg i.v PRN
Pantoprazole 40 mg i.v B.I.D
Routine blood tests daily
Stool for occult blood and OGDscopy in advance.

17. Follow up :
On the 3rd day
Pt’s looked ill , pale , Afebrille ,
C/O epigastric pain, and frequent vomiting.
CBC :
HB reached 9.8
Stool for occult blood : negative
Renal profile : improving
Plan :
Blood transfusion 2 units
Gastro-Enterologist Consultation For urgent Upper GI endoscopy
.

20. OGDSCOPY report :
Severe Reflux Esophagitis
Diffuse erythmatous gastritis
No signs of recent bleeding.
Diagnosis :-
Severe Ischemic gastritis and Reflux Esophagitis.

22. Plan from the gastroenterologist:
Removal of the Intra-gastric balloon
NPO for 2 hrs
PPI B.I.D P.O for 6 months.
R/V after 6 months for upper GI endoscopy.

23. On discharge :
Pt’s looked well
Vomiting stopped and the pain resolved
Vital signs were stable
Lab results were convenient
Discharged on :
Pantoprazole 40 mg B.I.D P.O
Iron tab O.D P.O
Metclopromide 10 mg PRN P.O

24. •The final diagnosis :-
•Severe ischemic gastritis and Reflux
esophagitis, as a complication of Intra-gastric
balloon surgery which resulted in Microcytic
Hypochromic anaemia , altogther with
persistent vomiting that led to the
hypokalaemic alkalosis , Rhabdomyolysis and
Acute Kidney injury.

25. The end
Thank you all