Anaphylaxis: Recognition and Management.

Anaphylaxis is a life-threatening systemic reaction, normally occurring within one to two hours of exposure to an allergen. The incidence of anaphylaxis in the United States is 2.1 per 1,000 person-years. Most anaphylactic reactions occur outside the hospital setting. Urticaria, difficulty breathing, and mucosal swelling are the most common symptoms of anaphylaxis. The most common triggers are medications, stinging insect venoms, and foods; however, unidentified triggers occur in up to one-fifth of cases. Coexisting asthma, mast cell disorders, older age, underlying cardiovascular disease, peanut and tree nut allergy, and drug-induced reactions are associated with severe or fatal anaphylactic reactions. Clinicians can obtain serum tryptase levels, reflecting mast cell degranulation, when the clinical diagnosis of anaphylaxis is not clear. Acute management of anaphylaxis involves removal of the trigger; early administration of intramuscular epinephrine; supportive care for the patient's airway, breathing, and circulation; and a period of observation for potential biphasic reactions. Only after epinephrine administration should adjunct medications be considered; these include histamine H1 and H2 antagonists, corticosteroids, beta2 agonists, and glucagon. Patients should be monitored for a biphasic reaction (i.e., recurrence of anaphylaxis without reexposure to the allergen) for four to 12 hours, depending on risk factors for severe anaphylaxis. Following an anaphylactic reaction, management should focus on developing an emergency action plan, referral to an allergist, and patient education on avoidance of triggers and appropriate use of an epinephrine auto-injector.

A Bariatric Curveball: A Rare Case of Recurrent Lactobezoars after Roux-en-Y Gastric Bypass Surgery.

Bariatric surgery is a major risk factor for bezoar formation secondary to decreased gastric motility, gastric acidity, and pyloric function.1 This case is about a 49-year-old female veteran, 3 weeks status-post Roux-en-Y gastric bypass surgery, who presented with acute abdominal pain and oral intolerance. After being diagnosed with a bezoar and esophagogastroduodenoscopic removal, the patient had immediate relief of symptoms. Unfortunately, over the course of 4 months, this patient experienced three recurrent episodes of bezoar formation (with a possible fourth episode that could not be confirmed secondary to resolution of symptoms after administration of oral contrast load). Based on her dietary history and gross appearance of the bezoar, the patient was determined to have developed recurrent lactobezoars. Lactobezoars are composed of milk and mucous proteins and are commonly found in neonates with immature gastrointestinal tracts.7 This unusual complication demonstrates how current dietary recommendations encouraging dairy consumption to meet daily protein requirements may have increased this patient's risk for lactobezoar formation. This case illustrates the importance of balancing the risks and benefits of macronutrient requirements after bariatric surgery with postsurgical bezoar complications.