Collection due to leak after sleeve gastrectomy
Sleeve gastrectomy for weight loss 1 week earlier. Pain after eating a light meal. Tender upper abdomen with raised inflammatory markers.
CT abdomen and pelvis with oral and intravenous contrast
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200 ml of 5% Gastrografin was given 5 minutes before imaging.
Multiple small bubbles of free gas in the upper abdomen. There is a thin walled cavity containing air and fluid in the left upper quadrant adjacent to the proximal end of the gastric staple line. This is separate to the lumen of the stomach. A further well-defined fluid density focus is intimately related to the body of the stomach. The density of the fluid in the thin walled splenogastric recess cavity is higher than water but there is no hyperdense contrast within as is seen within the lumen of the proximal small bowel.
Whilst small bubbles of free gas may persist for days after surgery, clustering and coalescence are highly suggestive of a complication such as a leak, as was proven in this case. The density of the fluid in the collection is not as high as might be expected given the oral contrast, but the combination of dilution with native fluid and preferential passage of most of the contrast past a pinhole perforation are likely causes. Care must be taken to not mistake a small residual gastric fundus with a collection.
The second fluid density "collection" located further along the body of the stomach, and containing no gas, was confirmed by the surgeon to be a "glue ball", used for haemostatic control.