Case Report
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World J Hepatol. Nov 27, 2012; 4(11): 311-313
Published online Nov 27, 2012. doi: 10.4254/wjh.v4.i11.311
Acute liver failure complicating jejunojejunal intussusception presentation in a gastric bypass patient
Susan Kartiko, Jorge Ortiz, Nikroo Hashemi, Ronald Miick, Ramsey Dallal
Susan Kartiko, Jorge Ortiz, Ramsey Dallal, Department of Surgery, Albert Einstein Medical Center, Philadelphia, PA 19030, United States
Nikroo Hashemi, Department of Hepatology, Albert Einstein Medical Center, Philadelphia, PA 19030, United States
Ronald Miick, Department of Pathology and Laboratory Medicine, Albert Einstein Medical Center, Philadelphia, PA 19030, United States
Author contributions: Kartiko S contributed to data acquisition, drafting and final approval; Ortiz J, Hashemi N, Miick R and Dallal R contributed to data acquisition and final approval of the article.
Supported by Department of Surgery, Albert Einstein Medical Center
Correspondence to: Susan Kartiko, MD, PhD, Department of Surgery, Albert Einstein Medical Center, 5501 Old York Rd, Philadelphia, PA 19030, United States.
Telephone: +1-979-5713853 Fax: +1-215-4566387
Received: May 13, 2012
Revised: October 26, 2012
Accepted: November 2, 2012
Published online: November 27, 2012

Over 200 000 weight loss procedures are performed annually in the United States. Physicians must therefore be cognizant of the unique array of complications associated with these procedures. We describe a case of jejunojejunal intussusception in a gastric bypass patient who presented with acute liver failure (ALF) due to acetaminophen (APAP) toxicity. Our patient is a 29 year-old female who had undergone Roux-en-Y gastric bypass surgery seven years prior. She was evaluated in the emergency department for confusion. Her family reported a 3-wk history of progressive abdominal pain and vomiting, for which she had ingested 40 acetaminophen/oxycodone tablets over the past 2 d. Physical examination showed icteric sclerae, a distended abdomen, and grade I encephalopathy. She fulfilled the criteria for ALF and was listed for liver transplantation. Abdominal computed tomography scan revealed a jejunojejunal intussusception. She underwent emergent exploratory laparotomy and resection of the infarcted intussusceptum and the previous jejunojejunostomy. She had rapid clinical improvement, with decreasing liver enzymes and improved hepatic synthetic function. She had complete resolution of coagulopathy and encephalopathy, and was removed from the liver transplant list. She was discharged home 20 d after hospitalization with normal liver tests. This case demonstrates that acute abdominal catastrophes can potentiate liver injury in the setting of acetaminophen toxicity. Encephalopathy may obscure history and physical exam findings. This case also exemplifies the pitfalls in the management of the bariatric surgery patient and the importance of multispecialty collaboration in patients presenting with organ failure.

Keywords: Acute liver failure, Gastric bypass, Intussusception, Acetaminophen toxicity