Ileal bezoar causing bowel obstruction mimicking an internal hernia in a patient with Roux-en-Y gastric bypass.

We presented a case of a 64-year-old female patient with a history of gastric bypass that presented with bowel obstruction due to a bezoar. She arrived at the emergency department, referring to severe abdominal pain, nausea, and vomiting. Abdominal X-ray reported gastric distention and hydro-air levels. CT scan reported swirling of the mesentery vessels and a collapsed intestinal loop, mimicking an internal hernia. Laparotomy was accomplished, which shows obstruction at 60 cm from the ileocecal valve. An enterolithotomy was performed, and a 6 × 6 cm phytobezoar was extracted. The patient had a satisfactory postoperative outcome, discharging her home on the fourth postoperative day. On a 12 month-follow up, the patient is doing well with no further complications. Gastric bypass continues to be one of the most performed bariatric procedures with low complication rates. It is important to note that not all intestinal obstructions in postoperative bariatric surgeries are due to internal hernias or adhesions. The differential diagnosis of intestinal obstruction due to bezoar must be present in patients who underwent bariatric surgery. Nutritional counseling is essential for the follow-up of patients, emphasizing fluid intake and slow chewing, as well as the use of absorbable materials for suture during the surgery.

Internal hernias in pregnant women with history of gastric bypass surgery: Case series and review of literature.

INTRODUCTION: Gastric bypass surgery is the most common obesity surgery procedure in women. Decreased weight loss favors fertility and leads to pregnancy sometimes just months after surgery, raising the risk of developing gastric bypass-related complications during pregnancy, including the formation of internal hernias. PRESENTATION OF CASE: The first patient presented at 37 weeks of gestation with abdominal pain, nausea and vomiting. X-ray revealed multiple air-fluid levels and absence of gas in colon. She underwent a cesarean section and exploratory laparotomy without complications. A Petersen's space internal hernia was found. The second patient presented at 25 weeks of gestation with abdominal pain and nausea. X-ray revealed multiple air-fluid levels and a "U-shaped" intestinal loop. She underwent exploratory laparotomy with reduction of an internal hernia also in Petersen's space. DISCUSSION: Pregnant patients with internal hernias after gastric bypass are usually of young age and with a several-day history of abdominal pain. Surgical exploration is safe and should not be delayed. The literature review showed that maternal death (9%) and fetal death (13.6%) rates are considerably high. CONCLUSION: The possibility of an internal hernia should always be considered in pregnant women with history of gastric bypass who present with abdominal pain, in order to prevent catastrophic outcomes such as maternal and/or fetal death.