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Published previously in Gastroenterology (2016;151:250-1)
By Andrew C. Storm, MD, and Christopher C. Thompson, MD, MSc
Dr. Storm and Dr. Thompson are in the department of medicine, division of
gastroenterology, hepatology and endoscopy, Brigham and Women’s Hospital,
Boston. Dr. Thompson is a consultant for Olympus, Cook, and Boston Scientific.
A45-year-old female with history of morbid obesity who had undergone Roux-en-Y gastric bypass (RYGB) 6 months ago for weight loss presents to the emergency department with acute onset chronic abdominal pain. She reports that these upper gastrointestinal symptoms have
been occurring with increasing frequency
over the past 2 months. Her pain is epigastric, postprandial, and without radiation.
It is associated with nausea, vomiting, and
early satiety. She denies fever, and reports
that these intermittent obstructive symptoms occur after meals and only resolve
after vomiting and regurgitation of the meal.
She denies symptoms of hematemesis, constipation, odynophagia,
or dysphagia. Physical examination reveals an obese woman in no
acute distress. Her pulse is regular, abdomen is moderately distended with normal bowel sounds, and is nontender. Blood chemistries
and CBC are normal. An upper endoscopy is performed showing
post-RYGB anatomy with a normal gastric pouch. The gastrojejunal
anastomosis is patent and 12 mm in diameter with unraveled suture
and staple material present (Figure A). The jejunum is otherwise
normal and nondilated to 60 cm beyond the anastomosis.
How should this patient be managed?
A. Symptomatic management with antiemetics and IV fluids
B. Endoscopic suture and staple removal
C. Referral for laparoscopic surgical revision
D. Upper GI series with gastrograffin
E. Balloon dilation of the gastrojejunal anastomosis
See The Answer on page 24