Small Bowel Ischemia after Roux-en-Y Gastric Bypass Complicated by Pregnancy: A Case Report

Small bowel obstruction is an unusual complication of pregnancy. Its occurrence after Roux- en-Y gastric bypass (RYGB) for morbid obesity complicated by pregnancy is rare. Morbid obesity describes body weight at least 100 lb over the ideal weight, or a body mass index (BMI) ≥40. Surgery offers the only viable treatment option with long-term weight loss and maintenance. This case report involves a 23-year-old female at 25 weeks gestation with a 1-day history of diffuse abdominal pain and vomiting. She had a RYGB with a 15 cc micropouch 6 months prior to the commencement of this pregnancy. All radiologic investigations were normal. Esophagogastroscopy was performed revealing an ischemic Roux limb of the gastric bypass. At laparotomy, an internal hernia involving the afferent limb was identified at the site of the Roux anastomosis compromising portions of both the afferent and Roux limbs. Nonviable portions of both the afferent and Roux limbs were resected. Gastrointestinal continuity was achieved by fashioning a gastro-gastrostomy and a jejuno-jejunostomy, thus reversing the original gastric bypass procedure. The immediate postoperative period was complicated by fetal demise. With the increase in bariatric surgery, small bowel ischemia after Roux- en-Y gastric bypass will most likely become more prevalent, particularly in women of childbearing age.

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Small bowel ischemia as an unusual complication of Henoch‐Schönlein purpura in an adult: A case report

Advances in Digestive Medicine ◽

10.1002/aid2.13174 ◽

2020 ◽

Vol 7 (3) ◽

pp. 162-165

Author(s):

Meng‐Yu Ko ◽

Chi‐En Yen ◽

Yu‐Chun Hsu ◽

Chih‐Jung Chen ◽

Hsu‐Heng Yen

Keyword(s):

Case Report ◽

Small Bowel ◽

Bowel Ischemia ◽

Unusual Complication ◽

Henoch Schonlein Purpura ◽

Schonlein Purpura ◽

Henoch Schönlein Purpura

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Small Bowel Ischemia due to Jejunum Volvulus in Pregnancy: A Case Report

Case Reports in Obstetrics and Gynecology ◽

10.1155/2012/485863 ◽

2012 ◽

Vol 2012 ◽

pp. 1-2 ◽

Cited By ~ 3

Author(s):

Ioannis Vassiliou ◽

Aliki Tympa ◽

Michalis Derpapas ◽

Georgios Kottis ◽

Nikolaos Vlahos

Keyword(s):

Abdominal Pain ◽

Case Report ◽

Small Bowel ◽

Mortality Rate ◽

Intestinal Obstruction ◽

Open Repair ◽

Bowel Ischemia ◽

Midgut Volvulus ◽

History Of ◽

In Pregnancy

The diagnosis of intestinal obstruction in pregnancy is difficult, as the symptoms may mimic pregnancy-associated complaints. The surgical management is challenging, as the mortality rate of midgut volvulus in pregnancy is high. We report the case of a 35-year-old woman at 21 weeks and 5 days of gestation with small bowel obstruction who presented to our institution with a 24 h history of colicky abdominal pain and nausea and who finally had a successful open repair.

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Internal herniation during pregnancy after banded Roux-en-Y gastric bypass: a unique location

BMJ Case Reports ◽

10.1136/bcr-2020-236798 ◽

2020 ◽

Vol 13 (12) ◽

pp. e236798

Author(s):

Daniëlle Susan Bonouvrie ◽

Evert-Jan Boerma ◽

Francois M H van Dielen ◽

Wouter K G Leclercq

Keyword(s):

Gastric Bypass ◽

Small Bowel ◽

Neonatal Intensive Care ◽

Postoperative Recovery ◽

Internal Herniation ◽

Referral Centre ◽

Mri Scan ◽

Tertiary Referral Centre ◽

Bariatric Complications ◽

History Of

A 26-year-old multigravida, 30+3 weeks pregnant woman, was referred to our tertiary referral centre with acute abdominal pain and vomiting suspected for internal herniation. She had a history of a primary banded Roux-en-Y gastric bypass (B-RYGB). The MRI scan showed a clustered small bowel package with possible mesenteric swirl diagnosed as internal herniation. A diagnostic laparoscopy was converted to laparotomy showing an internal herniation of the alimentary limb through the silicone ring. The internal herniation was reduced by cutting the silicone ring. Postoperative recovery, remaining pregnancy and labour were uneventful. During pregnancy after B-RYGB, small bowel obstruction can in rare cases occur due to internal herniation through the silicone ring. Education regarding this complication should be provided before bariatric surgery. Treatment of women, 24 to 32 weeks pregnant, in a specialised centre for bariatric complications with a neonatal intensive care unit is advised to improve maternal and neonatal outcome.

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Internal hernia following total gastrectomy with Roux-en-Y reconstruction

Annals of The Royal College of Surgeons of England ◽

10.1308/147870811x590333 ◽

2011 ◽

Vol 93 (6) ◽

pp. e71-e73 ◽

Cited By ~ 4

Author(s):

JO Larkin ◽

F Cooke ◽

N Ravi ◽

JV Reynolds

Keyword(s):

Gastric Bypass ◽

Small Bowel ◽

Total Gastrectomy ◽

Internal Hernia ◽

Bypass Surgery ◽

Gastric Bypass Surgery ◽

Postoperative Recovery ◽

Entire Small Bowel ◽

History Of ◽

Swirl Sign

Internal herniation is a well-described complication after a gastric bypass, particularly when performed laparoscopically, although it is rarely described following a total gastrectomy. A 55-year-old lady presented with a 24-hour history of vomiting and rigors 10 months after a radical total gastrectomy with Roux-en-Y reconstruction for a gastric adenocarcinoma. Computed tomography (CT) showed a complete small bowel obstruction and a mesenteric swirl sign, indicating a possible internal hernia. The entire small bowel was found at laparotomy to have migrated through the mesenteric defect adjacent to the site of the previous jejunojejunostomy and was dark purple and aperistaltic. The small bowel was reduced through the defect. At a second laparotomy, the small bowel looked healthy and the defect was repaired. Postoperative recovery was unremarkable. Of numerous signs described, the mesenteric swirl sign is considered the best indicator on CT of an internal hernia following Roux-en-Y reconstruction in gastric bypass surgery. A swirl sign on CT in a patient with abdominal pain should always raise the suspicion of an internal hernia.

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Predictors of Ischemic Bowel in Patients with Small Bowel Obstruction

The American Surgeon ◽

10.1177/000313481608201030 ◽

2016 ◽

Vol 82 (10) ◽

pp. 992-994 ◽

Cited By ~ 6

Author(s):

Michael P. O'Leary ◽

Angela L. Neville ◽

Jessica A. Keeley ◽

Dennis Y. Kim ◽

Christian De Virgilio ◽

...

Keyword(s):

Small Bowel ◽

Small Bowel Obstruction ◽

Bowel Obstruction ◽

Bowel Ischemia ◽

Wall Thickening ◽

Ischemic Bowel ◽

Operative Exploration ◽

Common Etiology ◽

History Of ◽

Exploratory Laparoscopy

Preoperative diagnosis of ischemic bowel in patients with small bowel obstruction (SBO) is a clinical challenge. The aim of this study was to identify preoperative variables associated with ischemic bowel found at operative exploration. We performed a 5-year retrospective review of patients admitted to a university affiliated, county funded hospital who underwent exploratory laparoscopy or laparotomy for SBO. Patients were excluded if they had a known preoperative malignancy or hernia on physical examination. Multivariate logistic regression was used to determine factors independently associated with bowel ischemia or ischemic perforation. One hundred and sixteen patients underwent exploratory surgery for SBO. Mean age was 52 ± 14 years and most were male [64 (55.2%)]. Adhesions [92 (79.3%)] were the most common etiology of obstruction. Leukocytosis ( P = 0.304) and acidosis ( P = 0.151) were not significantly associated with ischemia or ischemic perforation. In addition, history of prior SBO ( P = 0.618), tachycardia ( P = 0.111), fever ( P = 0.859), and time from admission to operation ( P = 0.383) were not predictive of ischemic bowel. However, hyponatremia (≤134 mmol/L) and CT scan findings of wall thickening or a suspected closed loop were independently associated with bowel ischemia. Awareness of these predictors should heighten the concern for ischemic bowel in patients presenting with SBO.

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