Gastric sleeve surgery is a frequently performed procedure. Although it is one of the safest bariatric procedures, it is like any other operation that carries significant risks and complications. Moreover, the hepatic abscess is an infrequent complication of laparoscopic gastric sleeve surgery, the infected late gastric leakage is a rare etiology of the hepatic abscess. We present a case of liver abscess developed one month after sleeve gastrectomy secondary to infected walled-off late-gastric leak. The case highlights this rare complication of gastric sleeve surgery. Moreover, early treatment of liver abscesses with imaging-guided drainage and intravenous antibiotics can prevent life-threatening outcomes.

BackgroundLaparoscopic sleeve gastrectomy (LSG) is a common bariatric procedure for weight loss. LSG is becoming prevalent worldwide because it is a relatively simple procedure with high efficacy. Reduced intraabdominal pressure may improve gastroesophageal reflux disease (GERD) symptoms and reduce the GERD medication needed following LSG. However, the main long-term drawback of LSG is the development of de novo GERD. Therefore, we conducted this study to determine the relationship between GERD symptoms and LSG. MethodsWe conducted a retrospective chart review involving 390 patients who underwent LSG. Study participants were evaluated for GERD symptoms six months before and three, six, and nine months after the procedure, and proton-pump inhibitors (PPIs) were used to control the symptoms. Participants were distributed into two groups: one group for patients with GERD symptoms (36.1%) and one group for asymptomatic patients (62.8%). We collected demographic data and assessed PPI use in both groups after three, six, and nine months postoperatively. Data were collected using Microsoft Excel (Microsoft Corporation, Redmond, WA) and analyzed using IBM SPSS Statistics for Windows, Version 20.0 (Armonk, NY: IBM Corp.). We compared data using the student's t-test for independent groups. The quantitative data were summarized using mean and standard deviation (SD), and p < 0.05 was considered statistically significant. ResultsOf the 390 participants who underwent LSG, 83.8% were women (n=327) and 16.2% were men (n=63), with a median age of 42 ± 11.9 years. PPI use was statistically significantly greater after LSG (34.1%) than before LSG (24.6%, p=0.019). The difference in PPI use between symptomatic and asymptomatic groups was not statistically significant three months after LSG. ConclusionsOur study focuses on using PPI after LSG due to GERD symptoms. We found GERD symptoms improved three months following LSG, but de novo GERD symptoms occurred nine months after the surgery. Health providers need to discuss with their patients the potential outcomes of the surgery and manage patient expectations. Physicians should work with their patients to assess whether the benefits of bariatric surgery in controlling overweight-associated conditions, such as blood pressure, diabetes, sleep apnea, and weight loss, outweigh the risk of GERD symptoms and PPI use.

Cefepime is a fourth-generation cephalosporin usually reserved to treat severe infections or those caused by multi-resistant microorganisms. Neurotoxicity is attributed to its ability to cross the blood-brain barrier and produce gamma-aminobutyric acid antagonism. Neurological symptoms may range from mild somnolence to seizures and coma. Our patient is an 88-year-old man who presented from a nursing home due to worsening pressure ulcers. After cefepime was started, he started developing worsening altered mental status and hallucinations. Cefepime was discontinued and his neurological symptoms improved shortly afterward. He was discharged to a long-term acute facility for antibiotic therapy where he recovered. Our case illustrates a commonly missed side effect of cefepime. Prompt recognition of this adverse effect is paramount to prevent disease progression and avoid permanent neurological damage.

Myxedema coma is an extreme manifestation of hypothyroidism. It is characterized by altered mental status and hypothermia. The most common precipitants of myxedema coma include discontinuation of thyroid supplements and infections. Therefore, the mainstay of treatment is IV glucocorticoids and IV levothyroxine. We describe a case of an 81-year-old woman with myxedema coma who developed acute cardiopulmonary failure with associated pericardial and pleural effusions, which are rare manifestations of myxedema coma.

Left-sided infective endocarditis (IE) is a condition prevalent among patients with indwelling catheters. Once a vegetation has been established, the infected valve's embolizing septic products migrate towards the systemic circulation, potentially disrupting the brain parenchyma's normal architecture [1]. CASE PRESENTATION:A 79-year-old female with a history of end-stage renal disease on hemodialysis and morbid obesity presented with dysuria and low blood pressure. Examination showed hypotension and tachycardia. Work-up revealed leukocytosis and bandemia. The urinalysis was infectious, and a chest x-ray showed a consolidation in the left lower lobe. IV fluids and broadspectrum antibiotics were immediately started with mild clinical improvement. Urine cultures revealed Staphylococcus aureus, Proteus mirabilis, and Escherichia coli. Blood cultures grew S. aureus. The patient's dysuria had improved after two days of treatment, but her blood pressure remained critically low, requiring vasopressors. Even though the dialysis catheter was replaced, suspicion for IE was imperative. Transthoracic echocardiogram (TTE) showed an ejection fraction of 60% with no obvious vegetations. Transesophageal echocardiogram (TEE) revealed a non-oscillating mass on the aortic valve, suspicious for vegetations. Shortly afterward, the patient developed progressive altered mental status but without focal neurological deficits or seizures. A brain diffusion-weighted magnetic resonance imaging displayed multiple foci of diffusion restriction in the cerebrum, pons, and cerebellum bilaterally. Additionally, a corresponding low apparent diffusion coefficient was observed, consistent with ischemia. Further workup of diffusion restriction lesions showed normal levels of carbon monoxide, anion gap, blood glucose, and ammonia. Unfortunately, the patient became hypotensive, bradycardic, and unresponsive during a hemodialysis session and expired thereafter.DISCUSSION: IE might prove a challenging diagnosis when potential confounders entangle the initial clinical assessment. This patient had different sources of infection that explained the initial findings. Prompt clinical suspicion is paramount when there's a lack of clinical improvement on optimal medical therapy. TTE had no evidence of IE but, in a morbidly obese patient, this isn't an irregular finding. Therefore, TEE is key for diagnosis in this patient population [2]. Moreover, even though active septic embolization is an indication for surgical evaluation, the patient's comorbidities and personal wishes withheld further interventions [3].CONCLUSIONS: IE's mortality can be up to 40% in some cases and neurological complications worsen survival probabilities. Single tests may be equivocal so a combination of clinical findings and diagnostic studies is recommended. Prompt surgical evaluation might be lifesaving when the cardiovascular shower has ensued.