Chronic Abdominal Pain in Roux-en-Y Gastric Bypass and Biliopancreatic Diversion-Duodenal Switch Patients

| November 2, 2014

by Rena C. Moon, MD; Andre F. Teixeira, MD; Muhammad A. Jawad, MD, FACS

Rena C. Moon, MD; Andre F. Teixeira, MD; and Muhammad A. Jawad, MD, FACS, are from the Department of Bariatric Surgery, Orlando Regional Medical Center & Bariatric and Laparoscopy Center,
Orlando Health.

FUNDING: No funding was provided.
DISCLOSURES: The authors reports no conflicts of interest to the content of this article.

Bariatric Times. 2014;11(11):14–16.

ABSTRACT
Abdominal pain is a common presentation following Roux-en-Y gastric bypass and bilio-pancreatic diversion-duodenal switch procedures. Causes of abdominal pain are diverse in this patient population, and some may warrant an urgent intervention.

We have reviewed current literatures using PubMed, and added our experience to list the causes of abdominal pain after Roux-en-Y gastric bypass and bilio-pancreatic diversion-duodenal switch. Thorough history taking and review of clinical signs are important when a patient presents with abdominal pain. Surgical exploration is necessary and more common in this patient population, if the diagnosis cannot be made using non-invasive measures.

Introduction
Roux-en-Y gastric bypass (GBP) and biliopancreatic diversion-duodenal switch (BPD-DS) are both created to bypass certain portions of the intestine and induce malabsorption for the purpose of weight loss. After jejunonoileal bypass essentially being abandoned due to its extensive complications, only these two procedures remain as a malabsorptive procedure of the six historically dominant bariatric procedures.[1] Although the trend showed a slight decrease in the percentage of GBP performed from 2008 to 2011, it was still the most commonly performed bariatric procedure worldwide.[2] On the contrary, due to difficulties of the procedure, the numbers of BPD-DS remain extremely low (<3%) worldwide.[2] An attempt has been made to make this procedure less technically challenging with less complications by reducing the anastomosis to one.[3,4] Not much is published regarding abdominal pain following BPD-DS, mostly due to the small number of procedures performed. However, abdominal pain is one of the most common complaint following GBP,[5,6] with highly variable clinical presentation.[7] Greenstein et al[8] have categorized diverse etiologies of abdominal pain following GBP. By adding our experience and current literatures, we will review common and rare causes of chronic abdominal pain following GBP and BPD-DS procedures (Table 1).

Behavioral and Nutritional Causes
Overeating and rapid eating. In the early postoperative period, GBP and BPD-DS patients may develop epigastric and postprandial abdominal pain due to maladaptive eating behaviors. Modifying the behavior to eat slowly and use defined portion sizes provides relief.[8]
Food intolerance. Food intolerance varies highly between individuals. Starches, meat, and some fruits and vegetables should be introduced slowly, eaten in small quantities, or avoided. Common foods that may be difficult to tolerate especially within the first six months are listed in Table 2.

Nutrient/vitamin deficiency. Iron and vitamin B12 deficiencies have been reported to cause abdominal pain.[9] Also, vitamin D deficiency was reported to cause chronic abdominal pain in some cases.10 These may apply to GBP and BPD-DS patients as well, and a routine follow-up diagnostic laboratory test should be necessitated to identify nutrient/vitamin deficiencies in these patients.

Functional Causes
Constipation/diarrhea. Constipation is common in the early postoperative period, and usually characterized by diffuse and crampy lower abdominal pain.[8] Diarrhea and/or increased flatus are less common in GBP patients, however, can be seen more frequently in BPD-DS patients.

Esophageal motility disorder. Esophageal motility disorders are increased in prevalence in obesity and may cause pain after GBP and BPD-DS that is typically substernal in location. Dysphagia may be present as well. Manometric studies can aid in the diagnosis.[8,11] We prefer conservative management, including dietary modification and calcium channel blockers if indicated by the manometric testing.

Biliary Causes
Cholelithiasis. Obesity itself, and rapid weight loss after a bariatric surgery have been known factors of inducing gallstones postoperatively[12] (Figure 1). The incidence of cholelithiasis after GBP was reported to be as high as 71 percent.[13,14] Theoretically, cholelithiasis should be less common after a sleeve gastrectomy than after a GBP, as the procedure does not alter the gastrointestinal pathway.[15] However, in our recent study, we found the frequency of symptomatic cholelithiasis after a GBP was not significantly different from that after a sleeve gastrectomy, at a rate of six percent.[12] Bardaro et al[16] reported that the addition of postoperative prophylactic ursodeoxycholic acid treatment achieved successful results regarding the development of symptoms or complications related to gallbladder disease or gallstones following BPD-DS. Biliary colic should be identified using clinical signs and ultrasound imaging in GBP and BPD-DS patients, especially during the phase of rapid weight loss (first 12-18 months).

Choledocholithiasis. Although rare, some GBP patients may develop primary choledocholithiasis and its sequelae, including ascending cholangitis and pancreatitis. Common bile duct stones after GBP and BPD-DS can be difficult to treat as the postoperative alteration in the gastrointestinal tract does not permit easy endoscopic access to the biliary system in the standard fashion via an endoscopic retrograde cholangiopancreatography (ERCP). Laparoscopic transgastric endoscopic retrograde cholangiopancreatography, percutaneous transhepatic instrumentation of the common bile duct, and double-balloon enteroscopy-assisted ERCP can be attempted for cannulating the common bile duct and stone retrieval.[17–19] Pancreatitis may be present as a complication of common bile duct stones. These patients can also present with elevated liver enzymes and jaundice even when stones are not seen in the common bile duct.[20] Laparoscopic choledochoduodenostomy is another treatment option with minimal complications in experienced hands. We reported a resolution of abdominal pain in 11 GBP patients with common bile duct stones, pancreatitis and ascending cholangitis after laparoscopic choledochoduodenostomy.[20]

Gastric Causes
Gastric ulcers. Marginal ulceration (Figure 2) has been reported as one of the more common complications, ranging from 1 to 16 percent[21–24] in GBP and BPD-DS patients. Abdominal pain is the most common presentation of marginal ulcerations, generally epigastric, burning in nature, and often immediately postprandial.[8] Patients also may complain of nausea/vomiting, hematemesis/melena, anemia, or dysphagia.[25] Definitive diagnosis is made with upper endoscopy. It has been known to respond well to medical therapy with rare cases of perforation.[26,27] However, persistent ulcerations not responding to medical treatment may require a revision. We recently reported a significant portion (44%) of our GBP patients presenting with a marginal ulceration, perforated or not, eventually required a reoperation.[11] Ulcer disease may also affect the gastric remnant or duodenum in GBP patients. Although not widely performed, double balloon or shape-lock enteroscopy can be used for diagnosis in these cases.[28,29]

Leak/gastro-gastric fistula. Gastro-gastric fistula is a communication between the gastric pouch and the remnant stomach in GBP patients. It is thought to be caused by a late staple-line failure or a leak with abscess formation.[30,31] Although gastro-gastric fistula itself does not commonly present with abdominal pain, it can cause abdominal pain at the time of leakage. Other presenting symptoms can be fever and tachycardia along with nausea, vomiting, fatigue, and diarrhea.[32] Late clinical signs of gastro-gastric fistula include failure in weight loss as the food can travel through the fistula to the remnant stomach. Diagnosis is made with upper gastrointestinal studies. Some have reported successful closure of the fistula with endoscopic fibrin glue injection, however, surgical revision is required in most cases.[33]

Small-Bowel Related Causes
Internal hernia. Internal herniation is a well-documented complication of laparoscopic GBP leading to small bowel obstructions, with an incidence between 1 and 9 percent.[34,35] Attempts have been made to reduce the rate of this complication such as closure of Peterson’s defect, closure of the jejunojejunal mesenteric defect, and conversion to an antecolic approach.[36,37] Internal herniation is reported at a rate of 18 percent in BPD-DS patients as well.[38] Internal hernia patients often present with diffuse, episodic, and severe abdominal pain that lasts hours and may or may not be postprandial.[8] Due to difficulties in detecting internal herniation on standard imaging modalities such as computed tomography (CT) scans, surgical exploration remains common in any patient with a high clinical suspicion of internal hernia.[37] In our recent review for causes of small bowel obstruction after GBP, internal herniation accounted for 28 percent of these reoperations.[39]

Adhesions. Adhesive small-bowel obstruction is thought to occur less in the era of laparoscopy. However, this should always be considered when a patient present with abdominal pain after GBP.[40] We also found adhesions accounted for 48 percent of reoperations in our GBP patients suspicious of small bowel obstruction.[39] A band of adhesions can cause small bowel obstruction in BPD-DS patients as well,[41] and volvulus can be created around an adhesion.[42]

Trocar site hernia. Trocar site hernia is known to occur at an incidence of less than one percent, but should always be considered as a cause of abdominal pain in GBP and BPD-DS patients.[43,44] CT can aid in the diagnosis, and the hernia can be treated laparoscopically.

Intussusception. Although rare, jejuno-jejunal intussusception (Figures 3 and 4) can be a cause of abdominal pain in GBP patients. In our experience, the majority of patients presented with upper quadrant abdominal pain.[45] In most cases, the diagnosis was made intraoperatively, as preoperative CT can be nonspecific. While reduction of the intussusception is safe and effective, it can carry a risk of recurrence, and imbrication of the jejuno-jejunal anastomosis may be a more effective means of treatment.[45]

Blind limb syndrome. Enlargement or dilation of the blind limb can also cause postprandial abdominal pain in GBP patients due to distention. It can be treated with resection of the elongated blind limb.

Other Causes
Other rare causes of abdominal pain include omental infarction, superior mesenteric artery syndrome, bezoar, gallstone ileus, and ileum ulcers.

Discussion
When a patient presents with abdominal pain in the immediate and early postoperative period, behavioral/nutritional and functional causes should be ruled out by thorough history taking and laboratory follow-up. Upper gastrointestinal imaging (UGI) should be performed when a leakage is suspected.

Pitt et al[46] suggested CT scans and right upper quadrant ultrasound (when gallbladder is present) if nothing is identified in UGI and upper endoscopy. Gastric and small bowel causes, such as ulcers, fistula, internal herniation, and intussusception can occur years after the procedure. When the cause is unidentifiable via the methods mentioned above, diagnostic laparoscopy may be warranted.

Conclusions
Abdominal pain following a GBP or BPD-DS procedure can be challenging due to its diverse etiology. As patients present with a bypassed gastrointestinal tract anatomy, identifying the cause is also difficult using typical diagnostic tools. Thorough history taking and review of clinical signs are important. Common causes of abdominal pain in the general population such as cholecystitis and appendicitis should not be overlooked as well. Surgical exploration is necessary and more common in this patient population, if the diagnosis cannot be made using non-invasive measures.

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