Introduction: A Roux-en-Y gastric bypass (RYGB) is a common bariatric surgery for weight loss, reducing the stomach size by creating a small pouch and bypassing a portion of the small intestine. While effective, RYGB can lead to complications, including nutritional deficiencies, anastomotic strictures, and, rarely, gastric remnant issues1. This case details a patient with persistent abdominal distension and pain who was found to have a gastric outlet obstruction (GOO) related to her RYGB performed over 20 years ago.

Case: A 48-year-old female with sarcoidosis, rheumatoid arthritis, and a remote RYGB was admitted with septic shock secondary to MSSA bacteremia, complicated by mitral valve endocarditis and epidural abscess. Following abscess washout, the source of the bacteremia was determined to be cat scratches, and she recovered uneventfully. She also reported weeks of progressive bloating, abdominal pain, and poor appetite. CT imaging showed a fluid-filled and distended stomach. An upper GI study showed no evidence of obstruction of the efferent limb, suggesting an issue with the remnant stomach. A percutaneous gastrostomy (G)-tube was placed in the remnant stomach for decompression. Gastrograffin injected into the G-tube showed delayed gastric emptying with no contrast passage into the small bowel after 20 minutes, suggesting gastroparesis/gastric atony. A subsequent gastrograffin challenge showed contrast confined to the remnant, suspicious for GOO. The case was discussed amongst bariatrics and advanced gastroenterology teams, and the patient underwent an endoscopy through the G-tube, revealing a cratered ulcer at the pylorus of the excluded stomach and severe intrinsic stenosis which could not be traversed. She started on a proton pump inhibitor with plans for stricture balloon dilation. The patient was lost to follow-up and did not undergo the procedure.

Discussion: Acute gastric remnant dilation is a rare postoperative complication of Roux-en-Y gastric bypass (LRYGB) occurring in 0 – 0.8% of cases2. This finding is unusual because the remnant pouch, being bypassed, is generally not expected to be actively involved in the digestive process. Dilation can be due to ulcer formation in the remnant stomach, as in this case, and has also been associated with diabetes and gastroparesis. Delayed diagnosis may lead to gastric remnant perforation, organ failure, sepsis, and death. This case underscores the role of internal medicine in managing complex inpatient presentations, especially those with incidental findings. The use of diverse imaging and procedural modalities like CT, upper GI studies, endoscopy was essential in diagnosing this atypical complication following RYGB.