Post gastric bypass patients pose certain difficulties in evaluation of abdominal pain. Routine modalities, such as upper endoscopy are not able to evaluate the excluded gastric remnant, duodenum. Endoscopic evaluation of the gastric remnant, duodenum, proximal jejunum may be necessary to evaluate intestinal pathology, such as GI bleeding. Papasavas, et.al. has described trans-gastric ERCP in post gastric bypass patients. We describe a gastroduodenoscopy in a post gastric bypass patient.

The patient is a 23 year-old female 18 months out from a laparoscopic Roux-en-Y gastric bypass who presented with several months of severe, intermittent, crampy upper abdominal pain, occasionally associated with eating.

The patient's evaluation included upper endoscopy which revealed a normal gastric pouch after a gastric bypass. Colonoscopy revealed severe constipation. Two CT scans showed normal post gastric bypass anatomy and no evidence of port site herniation, or bowel obstruction. A right upper quadrant ultrasound revealed the presence of gallstones, but no evidence of acute cholecystitis or common duct obstruction. Lab work was unremarkable. Attempts at treatment of irritable bowel syndrome and acid suppression therapy did not ameliorate the symptoms.

The patient was taken to the OR for a laparoscopic cholecystectomy, endoscopy of the gastric remnant and the duodenum, and evaluation of the entire length of small bowel for adhesions or an internal hernia that could be causing an intermittent bowel obstruction.

We demonstrate a method of evaluating the gastric remnant and duodenum with endoscopy. The cause of the patient's abdominal pain appears to be due to intermittent bowel obstruction from an internal hernia under the mesentary of the roux limb. Suture closure of the mesenteric defect resulted in resolution of the patient's abdominal pain. This technique of evaluating the excluded proximal upper GI tract may be a useful tool in the care of the increasing numbers of gastric bypass patients.