ReviewAbdominal pain after gastric bypass: suspects and solutions
Section snippets
Behavioral and Nutritional Disorders
Maladaptive eating behavior is a common cause of abdominal pain in the early postoperative period. Gastric bypass alters satiety and patients may not perceive fullness until pouch distension to the point of pain. Such pain is typically epigastric and postprandial, and a careful dietary history usually reveals a correlation with rapid eating. Modifying behavior to eat slowly and use defined portion sizes provides relief. Such problems rarely persist beyond 6 months after surgery, after which
Functional Disorders
Functional gastrointestinal motility disorders may cause abdominal pain after gastric bypass. Obesity is an independent risk factor for multiple motility and other functional disorders of the gastrointestinal tract14, 15 and surgery may exacerbate pre-existing subclinical disease. Such problems are likely more common than realized, often represent diagnoses of exclusion, and are particularly difficult to manage because disease pathogenesis and diagnostic and treatment algorithms are poorly
Biliary Disease
Biliary colic is a well-known cause of abdominal pain after gastric bypass. The extreme weight loss after bariatric surgery may contribute to increased bile lithogenicity and is a widely accepted risk factor for cholelithiasis. Although the prevalence of cholelithiasis after bariatric surgery may exceed 40% in some series,27, 28, 29, 30 the addition of ursodiol prophylaxis in the modern era reduces these prevalence rates to less than 3%.27, 31 The role of concomitant prophylactic
Pouch-Related Disease
A number of problems can affect the gastric pouch after gastric bypass and cause abdominal pain, including ulcer disease, fistula, reflux disease, and stenosis.
Ulcer Disease
Ulcer disease within the gastric pouch or at the gastrojejunal anastomosis may arise at any point after gastric bypass and occurs in 2% to 15% of patients.41, 42 Gastrogastric fistula, retained pouch parietal cells, and excessive tension on the anastomosis have been implicated as causes. Gastrogastric fistula was more common in the era of undivided gastric bypass, with reported rates of up to 50%.43, 44 The advent of linear cutting staplers led to universal adoption of a divided gastric bypass,
Gastroesophageal Reflux Disease and Hiatus Hernia
Obesity is an independent risk factor for gastroesophageal reflux disease (GERD). Fortunately, gastric bypass achieves remission of pre-existing GERD in more than 85% of patients as a result of diversion of gastric contents from the gastroesophageal junction.59, 60 Persistent GERD after gastric bypass is generally not as severe as pre-existing disease, and most often is attributable to either retained pouch parietal cells or fistula as discussed earlier. Bile reflux also has been implicated as
Stenosis
Anastomotic stenosis most often presents within 3 months of surgery, with incidences ranging from 3% to 20%, most often between 5% and 10%.63, 64 Stenosis is characterized by dysphagia and is not a common cause of pain per se, but may accompany ulcer disease, anastomotic leak, or other pouch pathologies that are associated with pain. Isolated stenosis is rarely a cause of significant abdominal pain, and if pain is a dominant symptom other pathology should be sought. Stenosis appears to be more
Small-bowel–related Disease
Small-bowel–related complications that cause abdominal pain after gastric bypass include ventral and trocar site hernias, adhesive disease, internal hernias, and, rarely, intussusception.
Incisional Hernia, Adhesions
Although large ventral (incisional) hernias have been eliminated by laparoscopic bariatric surgery, trocar site hernias should always be considered in the patient with abdominal pain after gastric bypass. Trocar site hernias occur at an incidence of 0% to 1% after gastric bypass,65, 66 although this likely is an underreported entity. Computed tomography (CT) scan may be necessary to establish the diagnosis of a trocar site hernia in the patient with a thick subcutaneous abdominal wall fat pad.
Internal Hernia
Internal hernia is an important cause of abdominal pain after gastric bypass with an incidence ranging from 1% to 9%.69, 70, 71, 72, 73, 74, 75, 76 Although risk factors are not well defined, internal hernia is thought to occur most commonly within 2 to 3 years after primary gastric bypass, often in the context of significant weight loss. Other reports have suggested that pregnancy may predispose to internal hernia, presumably secondary to alterations in intra-abdominal anatomy from the
Types of Internal Hernia
Most Roux limbs in gastric bypass are positioned antecolic, although a minority are retrocolic, retrogastric, and even fewer are retrocolic, antegastric. These various anatomies are associated with different types of internal hernias (Fig. 1). Virtually any segment of small intestine can incarcerate in any type of internal hernia, although the biliary limb often is involved, and longer biliary limb lengths may be associated with an increased risk of herniation.70 A mesenteric hernia is created
Routine Closure of Internal Hernia Defects
Much debate surrounds the issue of prophylactic closure of internal hernia defects at the time of primary gastric bypass. The efficacy of such closures is questionable: suture closure of mesenteric fat is tenuous and does not heal, but rather scars or adheses; laparoscopy is associated with fewer adhesions, which may predispose to failure of these closures. Furthermore, with weight loss, previously closed defects may open as a result of fat loss within the mesentery. Although some advocate for
Presentation, Diagnosis, and Treatment of Internal Hernia
Internal hernia typically is associated with diffuse, episodic, severe abdominal pain that lasts hours and may or may not be postprandial. Pain may continue for months in those who do not seek treatment, but the risk of incarceration is always present. In the case of biliopancreatic limb obstruction, obstipation may not be present, further confusing diagnosis. CT signs of internal hernia have variable diagnostic predictive values, and signs of bowel obstruction may not be present until
Intussusception
Intussusception is a rare cause of abdominal pain after gastric bypass, occurring with an incidence of approximately .1%.68 Intussusception may occur months or years after gastric bypass and is associated with nausea, vomiting, abdominal pain, and bowel obstruction.86 Similar to internal hernia, intussusception may be transient and chronic. Intussusception often is retrograde with the jejunojejunostomy acting as a lead point and progressing proximally along either the alimentary or
Less Common Culprits
Stenosis of the jejunojejunostomy may cause abdominal pain, and occurs with an incidence of approximately .5%.90 The use of longer (60 mm) linear staplers may minimize this complication. Although early jejunojejunostomy stenosis may be caused by edema and often can be managed expectantly,91 surgical anastomotic revision may be required in the late postoperative period. Endoscopic dilation using double-balloon enteroscopy represents an alternative to surgical revision. Omental torsion and/or
General Diagnostic Approach
Given the broad differential diagnosis in the patient with abdominal pain after gastric bypass, diagnostic algorithms must be flexible and guided by clinical history and physical examination. A careful dietary and food history along with serum chemistries and vitamin levels may reveal behavioral or nutritional causes of pain that often are easily treated. Most patients, however, will require an esophagogastroduodenoscopy and a CT scan, which are good initial tests that provide a diagnosis in
Conclusions
Abdominal pain after gastric bypass is an important public health problem that presents significant diagnostic and therapeutic challenges. Its diverse causes require a broad evaluation that should be directed by history and clinical presentation. In the absence of a clear diagnosis, the threshold for surgical exploration should be low. Finally, an understanding of the pathogenesis of abdominal pain as it relates to surgical technique at primary gastric bypass will guide modifications of
Acknowledgments
Dr O'Rourke is supported by an American Surgical Association Foundation Fellowship Award and National Institutes of Health grant K08 DK074397.
The authors thank Lynn Kitagawa for the creation of Figure 1.
References (96)
- et al.
Emergency room visits after laparoscopic Roux-en-Y gastric bypass for morbid obesity
Surg Obes Relat Dis
(2008) - et al.
Patterns of readmission and reoperation within 90 days after Roux-en-Y gastric bypass
Surg Obes Relat Dis
(2009) - et al.
Severe folate deficiency masquerading as the syndrome of hemolysis, elevated liver enzymes, and low platelets
Obstet Gynecol
(1997) - et al.
Probiotics improve outcomes after Roux-en-Y gastric bypass surgery: a prospective randomized trial
J Gastrointest Surg
(2009) - et al.
Candy cane Roux syndrome—a possible complication after gastric bypass surgery
Surg Obes Relat Dis
(2007) - et al.
Obesity is related to multiple functional abdominal diseases
J Pediatr
(2009) - et al.
Postgastric bypass hyperinsulinemic hypoglycemia syndrome: characterization and response to a modified diet
Surg Obes Relat Dis
(2008) - et al.
Successful treatment of persistent hyperinsulinemic hypoglycemia with nifedipine in an adult patient
Endocr Pract
(2010) - et al.
Prevention of gallstone formation in morbidly obese patients undergoing rapid weight loss: results of a randomized controlled pilot study
J Surg Res
(2002) - et al.
Elective cholecystectomy after Roux-en-Y gastric bypass: why should asymptomatic gallstones be treated differently in morbidly obese patients?
Surg Obes Relat Dis
(2005)
Expectant management of the asymptomatic gallbladder at Roux-en-Y gastric bypass
Surg Obes Relat Dis
Accessing the common bile duct after Roux-en-Y gastric bypass
Surg Obes Relat Dis
Sphincter of Oddi dysfunction after Roux-en-Y gastric bypass
Surg Obes Relat Dis
Management of gastrogastric fistula after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1292 consecutive patients and review of literature
Surg Obes Relat Dis
Revisional surgery for failed restrictive bariatric operations
Surg Obes Relat Dis
Preoperative upper gastrointestinal endoscopy in obese patients undergoing bariatric surgery: is it necessary?
Surg Obes Relat Dis
Prevalence of Helicobacter pylori infection and value of preoperative testing and treatment in patients undergoing laparoscopic Roux-en-Y gastric bypass
Surg Obes Relat Dis
Incidence of marginal ulcers and the use of absorbable anastomotic sutures in laparoscopic Roux-en-Y gastric bypass
Surg Obes Relat Dis
Endoscopic evaluation of the defunctionalized stomach by using ShapeLock technology (with video)
Gastrointest Endosc
Double-balloon enteroscopy to facilitate retrograde PEG placement as access for therapeutic ERCP in patients with long-limb gastric bypass
Gastrointest Endosc
Bile reflux after Roux-en-Y gastric bypass: an unrecognized cause of postoperative pain
Surg Obes Relat Dis
Complications at gastrojejunostomy after laparoscopic Roux-en-Y gastric bypass: comparison between 21-and 25-mm circular staplers
Surg Obes Relat Dis
Internal hernia at Petersen's space after laparoscopic Roux-en-Y gastric bypass6.2 % incidence without closure—a single surgeon series of 1047 cases
Surg Obes Relat Dis
Internal hernias after laparoscopic Roux-en-Y gastric bypass
Am J Surg
Internal hernia after laparoscopic Roux-en-Y gastric bypass
Surg Obes Relat Dis
Frequency and management of internal hernias after laparoscopic antecolic antegastric Roux-en-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: review of 1400 consecutive cases
Surg Obes Relat Dis
Sensitivity and specificity of eight CT signs in the preoperative diagnosis of internal mesenteric hernia following Roux-en-Y gastric bypass surgery
Clin Radiol
Elective laparoscopy for herald symptoms of mesenteric/internal hernia after laparoscopic Roux-en-Y gastric bypass
Surg Obes Relat Dis
Retrospective analysis of abdominal pain in postoperative laparoscopic Roux-en-Y gastric bypass patients: is a simple algorithm the answer?
Surg Obes Relat Dis
Diagnostic laparoscopy for chronic abdominal pain after gastric bypass
Surg Obes Relat Dis
Small bowel obstruction due to antegrade and retrograde intussusception after gastric bypass: three case reports in two patients, literature review, and recommendations for diagnosis and treatment
Surg Obes Relat Dis
Diagnosis and management of partial small bowel obstruction after laparoscopic antecolic antegastric Roux-en-Y gastric bypass for morbid obesity
J Am Coll Surg
Early jejunojejunostomy obstruction after laparoscopic gastric bypass: case series and treatment algorithm
Surg Obes Relat Dis
Omental infarction: a cause of acute abdominal pain after antecolic gastric bypass
Surg Obes Relat Dis
The tethered bezoar as a delayed complication of laparoscopic Roux-en-Y gastric bypass: a case report
J Gastrointest Surg
Unusual case of gastric bezoar causing obstruction after Roux-en-Y gastric bypass
Surg Obes Relat Dis
Trends in bariatric surgical procedures
JAMA
One-year readmission rates at a high volume bariatric surgery center: laparoscopic adjustable gastric banding, laparoscopic gastric bypass, and vertical banded gastroplasty-Roux-en-Y gastric bypass
Obes Surg
Gastrointestinal symptoms are more intense in morbidly obese patients
Surg Endosc
Incidence of regurgitation after the banded gastric bypass
Obes Surg
Nausea, bloating and abdominal pain in the Roux-en-Y gastric bypass patient: more questions than answers
Obes Surg
Increased gastric cytokine production after Roux-en-Y gastric bypass for morbid obesity
Arch Surg
Microbial flora of the stomach after gastric bypass for morbid obesity
Obes Surg
Intestinal bacterial overgrowth after Roux-en-Y gastric bypass
Obes Surg
Gastro-esophageal reflux and esophageal motility disorders in morbidly obese patients
Obes Surg
Bowel habits after bariatric surgery
Obes Surg
Extra-intestinal manifestations associated with irritable bowel syndrome: a twin study
Aliment Pharmacol Ther
Manometric abnormalities and gastroesophageal reflux disease in the morbidly obese
Obes Surg
Cited by (65)
The risk and benefit of revisional vs. primary metabolic- bariatric surgery and drug therapy - A narrative review
2024, Metabolism: Clinical and ExperimentalPostbariatric hypoglycemia, abdominal pain and gastrointestinal symptoms after Roux-en-Y gastric bypass explored by continuous glucose monitoring.
2024, Obesity Research and Clinical PracticeChronic abdominal pain and quality of life after Roux-en-Y gastric bypass and sleeve gastrectomy – a cross-cohort analysis of two prospective longitudinal observational studies
2023, Surgery for Obesity and Related DiseasesEcological momentary assessment of gastrointestinal symptoms and risky eating behaviors in Roux-en-Y gastric bypass and sleeve gastrectomy patients
2021, Surgery for Obesity and Related Diseases