P4175 - Intestinal Ischemia as a Delayed Complication of Roux-en-Y Gastric Bypass

Scott R. Piechocki, MD, MS¹, Blake Savoie, MD², Daniel Raines, MD^2
1Louisiana State University Health Sciences Center, New Orleans, LA; ²LSU Health Sciences Center, New Orleans, LA

Introduction: Complications associated with Roux-en-Y gastric bypass (RYGB) surgeries include anastomotic leaks, bleeding, obstruction, perforation, internal hernia, and more. A less commonly described complication is intestinal ischemia, which can manifest with acute abdominal pain and/or gastrointestinal bleeding (GIB). We present two examples of patients with intestinal ischemia as a delayed complication after RYGB.

Case Description/Methods: A 36-year-old male with a history of RYGB experienced multiple attacks of acute, severe epigastric pain associated with hematochezia. He was hospitalized 6 times over a 12 month period with negative evaluation by EGD, colonoscopy, and CTA. Examination of the deep small bowel in the outpatient setting by device-assisted enteroscopy (DAE) via anterograde route demonstrated healthy appearing mucosa. At the patient’s 7^th hospitalization with abdominal pain and hematochezia, a repeat upper DAE demonstrated a 5 cm segment of multifocal ulceration in the jejunum (image A) distal to the GJ anastomosis which was tattooed at proximal and distal margins. Surgical resection of this segment was performed, which resulted in resolution of these attacks.

A 56-year-old female with a history of RYGB was admitted with nausea, vomiting, and severe abdominal pain. Evaluation by CT scan was remarkable for dilatation of the stomach, duodenum, and proximal small bowel loops concerning for obstruction. The patient underwent anterograde DAE which revealed inflammatory stenosis of the pancreaticobiliary limb (image B) that was grossly typical for ischemia. A laparotomy was performed which included lysis of adhesions and segmental resection of the diseased segment of small bowel. Pathology confirmed ischemic injury.

Discussion: Gastroenterologists caring for patients with a history of RYGB should be aware of the possible complications associated with the procedure. Intestinal ischemia is an uncommon complication that can occur in the setting of internal hernias, adhesions, volvulus, or without a clear trigger, as in our patients. It can manifest as abdominal pain and GIB which are unexplained by standard EGD or colonoscopy. Ischemic injury to the small bowel may be characterized by mucosal erythema, ulceration, and strictures in the acute setting but may appear normal between attacks. Physicians must consider the possibility of underlying intestinal ischemia in those with a previous RYGB who are experiencing discrete episodes of abdominal pain and/or GIB.



Disclosures:


Scott R. Piechocki, MD, MS¹, Blake Savoie, MD², Daniel Raines, MD². P4175 - Intestinal Ischemia as a Delayed Complication of Roux-en-Y Gastric Bypass, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.