Abstract
Roux-en-Y gastric bypass (RYGB) is a common surgical treatment for morbid obesity, but rare complications involving the excluded gastric remnant can pose significant challenges. A 65-year-old female with a history of RYGB presented with sudden onset of left upper quadrant abdominal pain, bloating, nausea, and loss of appetite. Laboratory tests revealed leukocytosis. An initial CT scan showed significant distention of the excluded stomach, suggesting possible obstruction. While preparing for percutaneous decompression, her abdominal pain worsened acutely. A repeat CT scan demonstrated decompression of the excluded stomach and new free fluid in the abdomen, indicating a perforation. Emergent exploratory laparotomy uncovered a large necrotic perforation in the excluded gastric remnant and extensive adhesions from prior surgeries. A partial gastrectomy and antrectomy were performed to remove the perforated tissue. Pathological examination revealed ulcerated gastric mucosa with acute and chronic inflammation, reactive gastropathy, and no evidence of Helicobacter pylori infection or malignancy. Postoperatively, the patient recovered well with supportive care and was discharged home. Diagnosing complications in the excluded stomach after RYGB is challenging due to altered anatomy and nonspecific symptoms. Maintaining a high index of suspicion is essential when evaluating post-RYGB patients with unexplained abdominal pain. Early recognition and prompt surgical intervention are critical for favorable outcomes in these patients.