Unusual Cause of Acute Abdominal Pain in a Roux-en-Y Gastric Bypass Patient

Timothy Koch,Timothy R Shope,Anand Nath,Mario Golocovsky,Bikram K Paul

doi:10.31487/j.ajscr.2020.03.04

Abstract

Abdominal pain after Roux-en-Y gastric bypass is an important potential complication. Perforation of an ulcer in the excluded duodenum is a rare occurrence in a patient who has undergone gastric bypass. We present a case of a 61-year-old female with a history of Roux-en-Y gastric bypass, who presented with acute right upper quadrant abdominal pain, which began 1 week after starting treatment with ibuprofen. The evaluation revealed tachycardia, epigastric/right upper abdominal tenderness and leukocytosis. CT abdomen without contrast, ultrasound examination and nuclear medicine scan of the gallbladder were unremarkable. Upper endoscopy revealed an ulcer just distal to her gastrojejunostomy. At exploratory laparotomy, a wellcontained perforation was identified on the anterior duodenal bulb. The perforated ulcer was debrided, the intestine closed with sutures and a drain was left in the abscess cavity. Conventional endoscopic access to bypassed duodenum and stomach is difficult after gastric bypass. In this case, the patient ingested oral ibuprofen and developed both a marginal ulceration as well as an ulceration of the excluded duodenal bulb. The latter finding is consistent with a nonsteroidal anti-inflammatory drug side-effect developing via a hematogenous exposure.

Highlights

The rising prevalence of overweight (Body Mass Index or BMI ≥ 25 kg/m2) and obesity (BMI ≥ 30 kg/m2) in more than 100 countries has been described as a global pandemic [1,2,3]
We present a case of a 61-year-old female with a history of Roux-en-Y gastric bypass, who presented with acute right upper quadrant abdominal pain, which began 1 week after starting treatment with ibuprofen
A 2016 survey revealed that Roux-en-Y gastric bypass (RYGB) was the primary bariatric surgical procedures in 191,326 individuals, and was the primary bariatric procedure in 30.1% of all patients [5]

Summary

Introduction

The rising prevalence of overweight (Body Mass Index or BMI ≥ 25 kg/m2) and obesity (BMI ≥ 30 kg/m2) in more than 100 countries has been described as a global pandemic [1,2,3]. This morbidly obese woman had tachycardia with a pulse rate of 105, but she was afebrile with stable blood pressure and respiration She had epigastric/right upper abdominal tenderness and a reducible ventral hernia. HIDA scan of the gallbladder was normal, with a calculated ejection fraction of 52% (1 hour after oral intake of fat) She underwent an upper endoscopy, which showed a 1 cm by 1 cm marginal ulceration just distal to the gastrojejunal anastomosis with no stigmata of bleeding. The severity of upper abdominal pain, her examination and the leukocytosis were not explained by the gastrojejunal ulceration She was taken to the operating room for exploratory laparotomy. The culture of the abscess grew polymicorbial flora and the histopathology of the ulcer and the abscess cavity was consistent with necrosis without any signs of malignancy She was discharged on a soft diet and a daily proton pump inhibitor. She was seen in the outpatient clinic 2 weeks after hospital discharge (4 weeks after surgery) and she was in good health

Findings

Discussion

Conclusion