Vague abdominal pain after Roux-en-Y gastric bypass: not always an internal herniation: case report and literature review

Abstract

Background: Roux-en-Y gastric bypass is a frequently carried out bariatric procedure, proven to be effective in the management of obesity and its accompanying health issues. Following its popularity, admission to the emergency department for abdominal pain is often seen with known early and late onset causes. We present a case of a young woman with vague abdominal pain years after her gastric bypass, who eventually underwent a resection of a ‘candy cane’ like biliopancreatic blind loop.

Methods: A healthy 23-year-old woman has been suffering of vague abdominal complaints after a gastric bypass procedure 4 years earlier. Postprandial pain, diarrhoea and abdominal distension were present at a daily to weekly basis. Several investigations and management options were administered by surgeons, gastroenterologists as well as endocrinologists. On a performed explorative laparoscopy, a large blind loop at the entero-enteric anastomosis was seen and resected.

Results: At current follow-up of 15 months the resection of the candy cane like blind end of the biliopancreatic loop resulted in a complete withdrawal of our patient’s symptoms. A tentative diagnosis of bacterial overgrowth in the blind loop was made.

Conclusions: Abdominal pain after gastric bypass is a frequent cause of admission to the emergency department. Besides the more serious complications, internal hernia is often withheld as possible diagnosis in the differential diagnosis of late onset, postprandial epigastric pain. This case report highlights another possibility. At initial surgery, a candy cane shaped blind loop should be avoided both at the gastro-jejunal as well as the entero-enteric anastomosis.

Keywords:

• Blind loop
• gastric bypass
• internal hernia
• candy cane
• bacterial overgrowth

Acknowledgements

The authors like to thank the department of abdominal surgery of the university hospital Antwerp for their support in discussing this case.

Disclosure statement

The authors report no conflict of interest.

Figure 1. Axial CT image of the upper abdomen after IV contrast administration and oral contrast intake. A blind-ending air and contrast containing intestinal loop (star) can be seen in between the descending colon (dotted arrow), the stomach pouch (white arrow) and the excluded part of the stomach (black arrow).

Figure 2. Coronal image of the abdomen nicely shows the blind-ending loop (star) extending from the entero-enteric anastomosis (thin arrows) into the left hypochondrium in between the descending colon (dotted arrow) and the stomach pouch (white arrow).