Chronic Abdominal Pain After Roux-en-Y Gastric Bypass

  • Pearl Ma
  • Kelvin Higa


The surgical and physiologic construct of Roux-en-Y gastric bypass (RYGB) leads to a unique set of potential complications that require routine follow-up by an experienced bariatric surgeon. Chronic abdominal pain after RYGB is particularly challenging and often requires thoughtful workup and possible surgical intervention. Patient history and physical examinations must be thorough, confirmed with radiographic imaging to support the diagnosis. Most common causes of abdominal pain after surgery include internal hernia, marginal ulcers, and adhesions causing intermittent bowel obstructions. Less frequent pathologies such as intussusception at the jejunojejunostomy, suture bezoars, candy cane (afferent limb) deformity, biliary pathology, and remnant gastritis can present with less obvious and consistent symptoms. Often, radiographic and endoscopic evaluations will be negative. Therefore, surgeons should have a low threshold for exploring post-RYGB patients for abdominal pain.


Abdominal pain Chronic Complications Roux-en-Y gastric bypass 


  1. 1.
    Buchwald H, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724–37.CrossRefGoogle Scholar
  2. 2.
    Kothari SN, et al. Long-term (>10-year) outcomes after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2017;13:972–8.CrossRefGoogle Scholar
  3. 3.
    Higa KD, Boone KB, Ho T. Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients – what have we learned? Obes Surg. 2000;10(6):509–13.CrossRefGoogle Scholar
  4. 4.
    Moon RC, et al. Management and treatment outcomes of marginal ulcers after Roux-en-Y gastric bypass at a single high volume bariatric center. Surg Obes Relat Dis. 2014;10(2):229–34.CrossRefGoogle Scholar
  5. 5.
    Faintuch J, et al. Severe protein-calorie malnutrition after bariatric procedures. Obes Surg. 2004;14(2):175–81.CrossRefGoogle Scholar
  6. 6.
    Rasmussen JJ, Fuller W, Ali MR. Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients. Surg Endosc. 2007;21(7):1090–4.CrossRefGoogle Scholar
  7. 7.
    Campos GM, et al. Laparoscopic reversal of Roux-en-Y gastric bypass: technique and utility for treatment of endocrine complications. Surg Obes Relat Dis. 2014;10(1):36–43.CrossRefGoogle Scholar
  8. 8.
    Lee CJ, et al. Hormonal response to a mixed-meal challenge after reversal of gastric bypass for hypoglycemia. J Clin Endocrinol Metab. 2013;98(7):E1208–12.CrossRefGoogle Scholar
  9. 9.
    Mala T. Postprandial hyperinsulinemic hypoglycemia after gastric bypass surgical treatment. Surg Obes Relat Dis. 2014;10(6):1220–5.CrossRefGoogle Scholar
  10. 10.
    Gribsholt SB, et al. Prevalence of self-reported symptoms after gastric bypass surgery for obesity. JAMA Surg. 2016;151(6):504–11.CrossRefGoogle Scholar
  11. 11.
    Hogestol IK, et al. Chronic abdominal pain and symptoms 5 years after gastric bypass for morbid obesity. Obes Surg. 2016;27:1438–45.CrossRefGoogle Scholar
  12. 12.
    Alsulaimy M, et al. The utility of diagnostic laparoscopy in post-bariatric surgery patients with chronic abdominal pain of unknown etiology. Obes Surg. 2017;27:1924–8.CrossRefGoogle Scholar
  13. 13.
    Pitt T, et al. Diagnostic laparoscopy for chronic abdominal pain after gastric bypass. Surg Obes Relat Dis. 2008;4(3):394–8. discussion 398CrossRefGoogle Scholar
  14. 14.
    Csendes A, Torres J, Burgos AM. Late marginal ulcers after gastric bypass for morbid obesity. Clinical and endoscopic findings and response to treatment. Obes Surg. 2011;21(9):1319–22.CrossRefGoogle Scholar
  15. 15.
    Dallal RM, Bailey LA. Ulcer disease after gastric bypass surgery. Surg Obes Relat Dis. 2006;2(4):455–9.CrossRefGoogle Scholar
  16. 16.
    Gumbs AA, Duffy AJ, Bell RL. Incidence and management of marginal ulceration after laparoscopic Roux-Y gastric bypass. Surg Obes Relat Dis. 2006;2(4):460–3.CrossRefGoogle Scholar
  17. 17.
    Patel RA, Brolin RE, Gandhi A. Revisional operations for marginal ulcer after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2009;5(3):317–22.CrossRefGoogle Scholar
  18. 18.
    Coblijn UK, et al. Development of ulcer disease after Roux-en-Y gastric bypass, incidence, risk factors, and patient presentation: a systematic review. Obes Surg. 2014;24(2):299–309.CrossRefGoogle Scholar
  19. 19.
    Sacks BC, 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;2(1):11–6.CrossRefGoogle Scholar
  20. 20.
    Azagury DE, et al. Marginal ulceration after Roux-en-Y gastric bypass surgery: characteristics, risk factors, treatment, and outcomes. Endoscopy. 2011;43(11):950–4.CrossRefGoogle Scholar
  21. 21.
    Bhayani NH, et al. Predictors of marginal ulcers after laparoscopic Roux-en-Y gastric bypass. J Surg Res. 2012;177(2):224–7.CrossRefGoogle Scholar
  22. 22.
    Bhutta HY, Ashley SW. Hypertension and marginal ulceration after gastric bypass. J Surg Res. 2013;185(2):509–10.CrossRefGoogle Scholar
  23. 23.
    Carrodeguas L, et al. Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature. Surg Obes Relat Dis. 2005;1(5):467–74.CrossRefGoogle Scholar
  24. 24.
    Mason EE, et al. Effect of gastric bypass on gastric secretion. Am J Surg. 1976;131(2):162–8.CrossRefGoogle Scholar
  25. 25.
    Wilson JA, et al. Predictors of endoscopic findings after Roux-en-Y gastric bypass. Am J Gastroenterol. 2006;101(10):2194–9.CrossRefGoogle Scholar
  26. 26.
    Maity P, et al. Smoking and the pathogenesis of gastroduodenal ulcer – recent mechanistic update. Mol Cell Biochem. 2003;253(1–2):329–38.CrossRefGoogle Scholar
  27. 27.
    Edholm D, Ottosson J, Sundbom M. Importance of pouch size in laparoscopic Roux-en-Y gastric bypass: a cohort study of 14,168 patients. Surg Endosc. 2016;30(5):2011–5.CrossRefGoogle Scholar
  28. 28.
    Capella JF, Capella RF. Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction. Obes Surg. 1999;9(1):22–7. discussion 28CrossRefGoogle Scholar
  29. 29.
    Felix EL, et al. Perforated marginal ulcers after laparoscopic gastric bypass. Surg Endosc. 2008;22(10):2128–32.CrossRefGoogle Scholar
  30. 30.
    Moon RC, et al. Indications and outcomes of reversal of Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2015;11(4):821–6.CrossRefGoogle Scholar
  31. 31.
    Zaveri H, et al. Indications and operative outcomes of gastric bypass reversal. Obes Surg. 2016;26:2285–90.CrossRefGoogle Scholar
  32. 32.
    Chau E, et al. Surgical management and outcomes of patients with marginal ulcer after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2015;11(5):1071–5.CrossRefGoogle Scholar
  33. 33.
    Elms L, et al. Causes of small bowel obstruction after Roux-en-Y gastric bypass: a review of 2,395 cases at a single institution. Surg Endosc. 2014;28(5):1624–8.CrossRefGoogle Scholar
  34. 34.
    Gandhi AD, Patel RA, Brolin RE. Elective laparoscopy for herald symptoms of mesenteric/internal hernia after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2009;5(2):144–9. discussion 149CrossRefGoogle Scholar
  35. 35.
    Karila-Cohen P, et al. Contribution of computed tomographic imaging to the management of acute abdominal pain after gastric bypass: correlation between radiological and surgical findings. Obes Surg. 2017;27:1961–72.CrossRefGoogle Scholar
  36. 36.
    Higa K, et al. Laparoscopic Roux-en-Y gastric bypass: 10-year follow-up. Surg Obes Relat Dis. 2011;7(4):516–25.CrossRefGoogle Scholar
  37. 37.
    Simper SC, et al. Laparoscopic reversal of gastric bypass with sleeve gastrectomy for treatment of recurrent retrograde intussusception and Roux stasis syndrome. Surg Obes Relat Dis. 2010;6(6):684–8.CrossRefGoogle Scholar
  38. 38.
    Simper SC, et al. Retrograde (reverse) jejunal intussusception might not be such a rare problem: a single group's experience of 23 cases. Surg Obes Relat Dis. 2008;4(2):77–83.CrossRefGoogle Scholar
  39. 39.
    Shaw D, Huddleston S, Beilman G. Anterograde intussusception following laparoscopic Roux-en-Y gastric bypass: a case report and review of the literature. Obes Surg. 2010;20(8):1191–4.CrossRefGoogle Scholar
  40. 40.
    Simper SC, et al. Retrograde (reverse) jejunal intussusception might not be such a rare problem: a single group’s experience of 23 cases. Surg Obes Relat Dis. 2008;4(2):77–83.CrossRefGoogle Scholar
  41. 41.
    Varban O, et al. Resection or reduction? The dilemma of managing retrograde intussusception after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2013;9(5):725–30.CrossRefGoogle Scholar
  42. 42.
    Stephenson D, et al. Intussusception after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 10(4):666–70.Google Scholar
  43. 43.
    Chang J, et al. Predictive factors of biliary complications after bariatric surgery. Surg Obes Relat Dis. 2016;12(9):1706–10.CrossRefGoogle Scholar
  44. 44.
    Tsirline VB, et al. How frequently and when do patients undergo cholecystectomy after bariatric surgery? Surg Obes Relat Dis. 2014;10(2):313–21.CrossRefGoogle Scholar
  45. 45.
    Coupaye M, et al. Evaluation of incidence of cholelithiasis after bariatric surgery in subjects treated or not treated with ursodeoxycholic acid. Surg Obes Relat Dis. 2016;13:681–5.CrossRefGoogle Scholar
  46. 46.
    Dallal RM, Cottam D. “Candy cane” Roux syndrome – a possible complication after gastric bypass surgery. Surg Obes Relat Dis. 2007;3(3):408–10.CrossRefGoogle Scholar
  47. 47.
    Romero-Mejia C, Camacho-Aguilera JF, Paipilla-Monroy O. “Candy cane” Roux syndrome in laparoscopic gastric by-pass. Cir Cir. 2010;78(4):347–51.PubMedGoogle Scholar
  48. 48.
    Patel C, et al. Use of flexible endoscopic scissors to cut obstructing suture material in gastric bypass patients. Obes Surg. 2008;18(3):336–9.CrossRefGoogle Scholar
  49. 49.
    Pratt JS, Van Noord M, Christison-Lagay E. The tethered bezoar as a delayed complication of laparoscopic Roux-en-Y gastric bypass: a case report. J Gastrointest Surg. 2007;11(5):690–2.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Pearl Ma
    • 1
    • 2
  • Kelvin Higa
    • 1
    • 2
  1. 1.Department of SurgeryUniversity of California San Francisco-FresnoFresnoUSA
  2. 2.Fresno Heart and Surgical HospitalFresnoUSA

Personalised recommendations