Abdominal pain after gastric bypass: suspects and solutions

doi:10.1016/j.amjsurg.2010.05.007

The American Journal of Surgery

Volume 201, Issue 6, June 2011, Pages 819-827

https://doi.org/10.1016/j.amjsurg.2010.05.007 Get rights and content

Abstract

Background

Gastric bypass remains the mainstay of surgical therapy for obesity. Abdominal pain after gastric bypass is common and accounts for up to half of all postoperative complaints and emergency room visits. This article reviews the most important causes of abdominal pain specific to gastric bypass and discusses management considerations.

Methods

The current surgical literature was reviewed using PubMed, with a focus on abdominal pain after gastric bypass and the known pathologies that underlie its pathogenesis.

Results

The etiologies of abdominal pain after gastric bypass are diverse. A thorough understanding of their pathogenesis impacts favorably on clinical outcomes.

Conclusions

The differential diagnosis for abdominal pain after gastric bypass is large and includes benign and life-threatening entities. 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 in patients with abdominal pain after gastric bypass should be low.

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)

M. Cho et al.
Emergency room visits after laparoscopic Roux-en-Y gastric bypass for morbid obesity
Surg Obes Relat Dis
(2008)
T.A. Kellogg et al.
Patterns of readmission and reoperation within 90 days after Roux-en-Y gastric bypass
Surg Obes Relat Dis
(2009)
S.P. Walker et al.
Severe folate deficiency masquerading as the syndrome of hemolysis, elevated liver enzymes, and low platelets
Obstet Gynecol
(1997)
G.A. Woodard et al.
Probiotics improve outcomes after Roux-en-Y gastric bypass surgery: a prospective randomized trial
J Gastrointest Surg
(2009)
R.M. Dallal et al.
Candy cane Roux syndrome—a possible complication after gastric bypass surgery
Surg Obes Relat Dis
(2007)
J.E. Teitelbaum et al.
Obesity is related to multiple functional abdominal diseases
J Pediatr
(2009)
T.A. Kellogg et al.
Postgastric bypass hyperinsulinemic hypoglycemia syndrome: characterization and response to a modified diet
Surg Obes Relat Dis
(2008)
N. Guseva et al.
Successful treatment of persistent hyperinsulinemic hypoglycemia with nifedipine in an adult patient
Endocr Pract
(2010)
L.J. Wudel 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)
D.E. Swartz 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)

D.D. Portenier et al.

Expectant management of the asymptomatic gallbladder at Roux-en-Y gastric bypass

Surg Obes Relat Dis

(2007)

A.R. Ahmed et al.

Accessing the common bile duct after Roux-en-Y gastric bypass

Surg Obes Relat Dis

(2007)

K.A. Morgan et al.

Sphincter of Oddi dysfunction after Roux-en-Y gastric bypass

Surg Obes Relat Dis

(2009)

L. Carrodeguas et al.

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

(2005)

B.A. Coakley et al.

Revisional surgery for failed restrictive bariatric operations

Surg Obes Relat Dis

(2008)

A. de Moura Almeida et al.

Preoperative upper gastrointestinal endoscopy in obese patients undergoing bariatric surgery: is it necessary?

Surg Obes Relat Dis

(2008)

P.K. Papasavas et al.

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

(2008)

B.C. Sacks et al.

Incidence of marginal ulcers and the use of absorbable anastomotic sutures in laparoscopic Roux-en-Y gastric bypass

Surg Obes Relat Dis

(2006)

R.D. Pai et al.

Endoscopic evaluation of the defunctionalized stomach by using ShapeLock technology (with video)

Gastrointest Endosc

(2007)

T.H. Baron

Double-balloon enteroscopy to facilitate retrograde PEG placement as access for therapeutic ERCP in patients with long-limb gastric bypass

Gastrointest Endosc

(2006)

D.E. Swartz et al.

Bile reflux after Roux-en-Y gastric bypass: an unrecognized cause of postoperative pain

Surg Obes Relat Dis

(2009)

W.J. Suggs et al.

Complications at gastrojejunostomy after laparoscopic Roux-en-Y gastric bypass: comparison between 21-and 25-mm circular staplers

Surg Obes Relat Dis

(2007)

R.W. Bauman et al.

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

(2009)

E. Garza et al.

Internal hernias after laparoscopic Roux-en-Y gastric bypass

Am J Surg

(2004)

B. Carmody et al.

Internal hernia after laparoscopic Roux-en-Y gastric bypass

Surg Obes Relat Dis

(2005)

M. Cho et al.

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

(2006)

J.D. Iannuccilli et al.

Sensitivity and specificity of eight CT signs in the preoperative diagnosis of internal mesenteric hernia following Roux-en-Y gastric bypass surgery

Clin Radiol

(2009)

A.D. Gandhi et al.

Elective laparoscopy for herald symptoms of mesenteric/internal hernia after laparoscopic Roux-en-Y gastric bypass

Surg Obes Relat Dis

(2009)

E.A. Agaba et al.

Retrospective analysis of abdominal pain in postoperative laparoscopic Roux-en-Y gastric bypass patients: is a simple algorithm the answer?

Surg Obes Relat Dis

(2008)

T. Pitt et al.

Diagnostic laparoscopy for chronic abdominal pain after gastric bypass

Surg Obes Relat Dis

(2008)

D.D. Coster et al.

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

(2008)

M. Cho et al.

Diagnosis and management of partial small bowel obstruction after laparoscopic antecolic antegastric Roux-en-Y gastric bypass for morbid obesity

J Am Coll Surg

(2006)

C.E. Lewis et al.

Early jejunojejunostomy obstruction after laparoscopic gastric bypass: case series and treatment algorithm

Surg Obes Relat Dis

(2009)

R.M. Dallal et al.

Omental infarction: a cause of acute abdominal pain after antecolic gastric bypass

Surg Obes Relat Dis

(2006)

J.S. Pratt et al.

The tethered bezoar as a delayed complication of laparoscopic Roux-en-Y gastric bypass: a case report

J Gastrointest Surg

(2007)

K. Steele et al.

Unusual case of gastric bezoar causing obstruction after Roux-en-Y gastric bypass

Surg Obes Relat Dis

(2006)

H.P. Santry et al.

Trends in bariatric surgical procedures

JAMA

(2005)

J. Saunders et al.

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

(2008)

A. Foster et al.

Gastrointestinal symptoms are more intense in morbidly obese patients

Surg Endosc

(2003)

C.H. Arasaki et al.

Incidence of regurgitation after the banded gastric bypass

Obes Surg

(2005)

G.A. Decker et al.

Nausea, bloating and abdominal pain in the Roux-en-Y gastric bypass patient: more questions than answers

Obes Surg

(2007)

J. Faintuch et al.

Increased gastric cytokine production after Roux-en-Y gastric bypass for morbid obesity

Arch Surg

(2007)

R.K. Ishida et al.

Microbial flora of the stomach after gastric bypass for morbid obesity

Obes Surg

(2007)

J.D. Machado et al.

Intestinal bacterial overgrowth after Roux-en-Y gastric bypass

Obes Surg

(2008)

M. Suter et al.

Gastro-esophageal reflux and esophageal motility disorders in morbidly obese patients

Obes Surg

(2004)

N. Potoczna et al.

Bowel habits after bariatric surgery

Obes Surg

(2008)

P. Svedberg et al.

Extra-intestinal manifestations associated with irritable bowel syndrome: a twin study

Aliment Pharmacol Ther

(2002)

D. Hong et al.

Manometric abnormalities and gastroesophageal reflux disease in the morbidly obese

Obes Surg

(2004)

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At two public hospitals in Norway (one University Hospital) 22 of 46 invited patients who reported abdominal pain more than weekly took part. Recruited from a prospective follow-up study of 546 patients 14.5 years after RYGB.
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ReviewAbdominal pain after gastric bypass: suspects and solutions

Abstract

Background

Methods

Results

Conclusions

Section snippets

Behavioral and Nutritional Disorders

Functional Disorders

Biliary Disease

Pouch-Related Disease

Ulcer Disease

Gastroesophageal Reflux Disease and Hiatus Hernia

Stenosis

Small-bowel–related Disease

Incisional Hernia, Adhesions

Internal Hernia

Types of Internal Hernia

Routine Closure of Internal Hernia Defects

Presentation, Diagnosis, and Treatment of Internal Hernia

Intussusception

Less Common Culprits

General Diagnostic Approach

Conclusions

Acknowledgments

Surg Obes Relat Dis

Surg Obes Relat Dis

Obstet Gynecol

J Gastrointest Surg

Surg Obes Relat Dis

J Pediatr

Surg Obes Relat Dis

Endocr Pract

J Surg Res

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Gastrointest Endosc

Gastrointest Endosc

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Am J Surg

Surg Obes Relat Dis

Surg Obes Relat Dis

Clin Radiol

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

J Am Coll Surg

Surg Obes Relat Dis

Surg Obes Relat Dis

J Gastrointest Surg

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

Review
Abdominal pain after gastric bypass: suspects and solutions