Skip to main content

Pancreatitis following bariatric surgery



The laparoscopic Roux-en-Y gastric bypass (LRYGBP) is the second most performed bariatric surgical procedure. With the increasing number of patients undergoing bariatric surgery, the number of complications is also growing. Early diagnosis and treatment of the complications is crucial.

Case presentation

A very unusual complication was met after an uneventful laparoscopic gastric bypass (LGBP) procedure due to an obstructing blood clot in the biliairy limb resulting in an acute pancreatitis and gastric distention, accompanied by an obstructing blood clot in the distal ileum causing small bowel obstruction. A review of the occurrence of these complications and the diagnosis and treatment is presented.


Post-bariatric acute pancreatitis is uncommon, but could be fatal. Blood clots should be considered as possible causes of small bowel obstruction, ileus or pancreatitis.

Peer Review reports

Key points

  • Pancreatitis shortly after bariatric surgery is unusual but can be fatal.

  • Post-bariatric pancreatitis may be caused by stasis due to small bowel obstruction.

  • An intraluminal hematoma should be considered in the differential diagnosis of post-operative small bowel obstruction.

  • Hemostasis during surgery is of significant importance.

  • Early diagnosis and treatment of pancreatitis is necessary.


The number of performed bariatric surgeries is increasing [1, 2]. The laparoscopic Roux-en-Y gastric bypass (LRYGBP) is the second most performed bariatric procedure with a low mortality and morbidity [2, 3]. Frequently described complications are anastomosis related, such as bleeding, leakage, stenosis of the anastomosis or intestinal obstruction [4]. However, pancreatitis directly following bariatric surgery is very uncommon. Pancreatitis mostly resolves without complications (80%), but in the case of a severe pancreatitis (20%), the complications can be fatal and result in death (3%) [5, 6]. A rare combination of complications following blood clots is described.

Case presentation

A 33-year-old female presented to the emergency room with progressive abdominal pain. The patient underwent a LRYGBP two days prior to her admission. The primary operation was uneventful. Our technique involves double stapling of the intestinal jejunal-jejunal anastomoses using two 60 mm 2.5 mm staplers. No bleeding problem was encountered during this operation. Postoperative, she received subcutaneous low-molecular weight heparin for one week. She did not have a relevant past history. Her current medications were citalopram, pantoprazole and nadroparin.

The abdominal pain had a sudden onset and increased gradually. The patient had continuous severe abdominal pain localized in the left hemi-abdomen, intensifying from time to time (colic). Other complaints were nausea and vomiting. Since the LGBP, the patient did not have any stool. Flatulence was present. During physical examination, the patient experienced a lot of pain. Temperature, heart rate and blood pressure were normal. The bowel sounds were high pitched during auscultation. Palpation of the abdomen was mostly tender in the left hemi-abdomen. Biochemical analysis showed a C reactive protein (CRP) of 47 mmol/L, white cell count of 19.0 × 10 9/L, a glomerular filtration rate of more than 90 and a lipase of 47 U/L.

An abdominal CT-scan showed severe dilatation of the excluded stomach, filled with fluid. The whole trajectory of the proximal small intestines was distended, up to the Y-anastomosis. Remarkable was that the more distal small bowel was also distended, almost up to the distal ileum. A hyperdensity was seen in the excluded stomach and in the proximal small intestines (Fig. 1).

Fig. 1
figure 1

CT abdomen on the day of presentation. The CT-scan shows dilatation of the excluded stomach and of the proximal small intestines with hyperdensity (arrow), which appeared to be intraluminal blood clots during laparoscopy

A laparoscopy was performed. During laparoscopy, an intraluminal obstruction was found proximal of the jejunojejunostomy, causing dilatation of the excluded stomach and biliairy limb. Both, the alimentary limb as well as the common channel were distended due to a bulk found at the distal ileum. The bulk was movable trough gentle massage into the colon. The mass was a large blood clot, which appeared as a hyperdensity on the abdominal CT scan (Fig. 1, arrow). Another obstructing blood clot in the distal biliairy limb was removed by opening the blind loop of this limb and removing the cause of obstruction. The severely distended excluded stomach was decompressed with diathermic perforation and suction, followed by closing the defect with a V-lock.

Postoperatively, the patient had a persisting tachycardia, severe abdominal pain and elevated infection parameters (CRP 455 mmol/L; white cell count of 37.8 0 × 10 9/L) and a lipase of 207 U/L. Another laparoscopy was performed, which showed no signs of anastomotic leakage. A pancreatitis was seen: the pancreas was edematous and the pancreatic body was enlarged. Treatment was the standard management of pancreatitis.

The acute pancreatitis had progressed with a lipase of 697 U/L. The patient developed fever, for which intravenous ceftriaxone and metronidazole was given.-

An ultrasonography of the abdomen showed no cholelithiasis as a cause of pancreatitis.

Repeated CT-scan of the abdomen showed an edematous pancreas and peripancreatic fat infiltration, without any sign of pancreatic necrosis or intra-abdominal abcess.

The symptoms of the patient improved during the course of her admission and the inflammation parameters normalized. She was discharged after 16 days.

Discussion and conclusions

Due to the increasing number of performed LRYGBP, clinicians may notice a rising number of its complications [1,2,3]. Early post-operative complications are anastomosis-leakage, gastrointestinal bleeding and small bowel obstruction [7]. Internal herniation, anastomotic strictures and marginal ulcerations occur in the long term [8].

Pancreatitis shortly after bariatric surgery is very uncommon in recent literature. One case of a fulminant pancreatitis after LRYGBP has been described, which resulted in death. The pancreatitis occurred 31 h after the procedure. A laparoscopy showed a blood clot in the jejunojejunostomy, causing obstruction of the alimentary and biliary limb [9]. A case report described acute pancreatitis after a Roux-en-Y gastric bypass due to reflux into the biliairy limb, however diagnostics did not show any sign of small bowel obstruction [10].

In a study on acute pancreatitis following bariatric surgery, the mean time-frame for developing pancreatitis was 3,5 years after bariatric surgical procedures [11].

A study reviewed retrospectively the effects of bariatric surgery on the outcome of acute pancreatitis. Gallstones have been found to be associated with post-bariatric pancreatitis [12].

Our patient did not have gallstones on ultrasonography. Three days prior to the pancreatitis, our patient underwent bariatric surgery, which was complicated by a small bowel obstruction (on CT-scan). During laparoscopy, we found an intraluminal hematoma in the jejunojejunostomy, causing intestinal stasis and dilatation of the small intestines and excluded stomach.

We hypothesize that stasis and reflux of gastrointestinal content, bile and pancreatic secretions caused the pancreatitis in our patient. Due to increasing pressure from an occluding blood clot distally in the small bowel, intestinal content retrogradely flowed into the biliairy limb, through the papilla of Vater into the pancreas. This probably activated the pancreatic enzymes, which explains elevated lipase, and resulted in a pancreatitis. Therefore, elevated serum pancreatic enzymes in bariatric patient should be given immediate attention.

Small bowel obstruction is a known complication of LGBP with an incidence of 1.9–7.3% [13, 14]. Common causes of small bowel obstruction are internal herniations, incarcerated port-site hernia, stenosis of the anastomosis, adhesions and intussusception. It is a well-known phenomenon that blood chemistry shows an elevated lipase concentration, in case of small bowel obstruction [15, 16]. Also pancreatitis has been described as sign of obstruction of the biliary limb due to internal herniation [15, 17, 18].

An intraluminal hematoma causing postoperative small bowel obstruction is a rare event [7]. We suppose that the blot clot was caused by bleeding from the staple line of the jejunojejunostomy or an intraluminal small vessel hemorrhage, since no bleeding was seen during the LGBP. Obtaining hemostasis during surgery is of significant importance.

Our patient used postoperatively prophylactic low-molecular weight heparin 2850 IU, which may have worsened the intraluminal bleeding. However, preventing venous thromboembolism in bariatric patients is of great importance and should not be passed [19].

In conclusion: pancreatitis is an uncommon short-term complication of bariatric surgical procedures. Post-bariatric pancreatitis may be caused by stasis following early small bowel obstruction. Elevated serum lipase or amylase could be a sign of stasis and thus the beginning of a pancreatitis. Most cases of pancreatitis are self-limiting, however, severe pancreatitis could be fatal. In case of intestinal obstruction and ileus and or pancreatitis, blood clots should be considered as possible causes.

Availability of data and materials

All data is contained within the manuscript and its additional files.



Computed tomography


Laparoscopic gastric bypass


Laparoscopic Roux-en-Y gastric bypass


  1. WHO. Obesity: preventing and managing the global epidemic. WHO technical report series. 2004.

    Google Scholar 

  2. Angrisani L, Santonicola A, Iovino P, Vitiello A, Higa K, Himpens J, Buchwald H, Scopinaro N. IFSO worldwide survey 2016: primary, Endoluminal, and Revisional procedures. Obes Surg. 2018.

    Article  Google Scholar 

  3. Angrisani L, Santonicola A, Iovino P, Formisano G, Buchwald H, Scopinaro N. Bariatric surgery worldwide 2013. Obes Surg. 2015;25(10):1822–32.

    Article  CAS  Google Scholar 

  4. Karmali S, Sharma A, Stadnyk J, Christiansen S, Cottreau D, Birch D. Bariatric surgery a primer. Can Fam Physician. 2010;56(9):873–9.

    PubMed  PubMed Central  Google Scholar 

  5. Johnson CD, Besselink MG, Carter R. Acute pancreatitis. BMJ. 2014;349:4859.

    Article  Google Scholar 

  6. Banks PA, Conwell DL, Toskes PP. The management of acute and chronic pancreatitis. Gastroenterol Hepatol (N Y). 2010 Feb;6(2 Suppl 5):1–16.

    Google Scholar 

  7. Acquafresca PA, Palermo M, Rogula T, Duza GE, Serra E. Early surgical complications after gastric by-pass: a literature review. Arq Bras Cir Dig. 2015;28(1):74–80.

    Article  Google Scholar 

  8. Palermo M, Acquafresca PA, Rogula T, Duza GE, Serra E. Late surgical complications after gastric by-pass: a literature review. Arq Bras Cir Dig. 2015;28(2):139–43.

    Article  Google Scholar 

  9. Wang C, Ren Y, Chen J, Hu Y, Yang J, Xu P, Pan Y, Li J. Fatal fulminant pancreatitis after laparoscopic gastric bypass surgery. Obes Surg. 2008;18(11):1498–501.

    Article  CAS  Google Scholar 

  10. Däster S, Borbély Y, Peterli R. Acute pancreatitis after roux-en-Y gastric bypass surgery due to reflux into biliopancreatic limb. Surg Obes Relat Dis. 2012;8(3):e37–9.

    Article  Google Scholar 

  11. Kumaravel A, Zelisko A, Schauer P, Lopez R, Kroh M, Stevens T. Acute pancreatitis in patients after bariatric surgery: incidence, outcomes, and risk factors. Obes Surg. 2014;24(12):2025–30.

    Article  Google Scholar 

  12. Krishna SG, Behzadi J, Hinton A, El-Dika S, Groce JR, Hussan H, Hart PA, Conwell DL. Effects of bariatric surgery on outcomes of patients with acute pancreatitis. Clin Gastroenterol Hepatol. 2016;14(7):1001–1010.e5.

    Article  Google Scholar 

  13. G G, Shankar S, Czerniach DR, Kelly JJ, Perugini RA. Small-bowel obstruction after laparoscopic roux-en-Y gastric bypass surgery. J Comput Assist Tomogr. 2009;33(3):369–75.

    Article  Google Scholar 

  14. Lewis CE, Jensen C, Tejirian T, Dutson E, Mehran A. Early jejunojejunostomy obstruction after laparoscopic gastric bypass: case series and treatment algorithm. Surg Obes Relat Dis. 2009;5(2):203–7.

    Article  Google Scholar 

  15. Spector D, Perry Z, Shah S, Kim JJ, Tarnoff ME, Shikora SA. Roux-en-Y gastric bypass: hyperamylasemia is associated with small bowel obstruction. Surg Obes Relat Dis. 2015;11(1):38–43.

    Article  Google Scholar 

  16. McGowan GK, Wills MR. Diagnostic value of plasma amylase, especially after gastrectomy. Br Med J. 1964;1:160–2.

    Article  CAS  Google Scholar 

  17. Kaya E, Senyürek G, Dervisoglu A, Danaci M, Kesim M. Acute pancreatitis caused by afferent loop herniation after Billroth II gastrectomy: report of a case and review of the literature. Hepatogastroenterology. 2004;51(56):606–8.

    PubMed  Google Scholar 

  18. Odell DD, Pratt WB, Callery MP, Vollmer CM Jr. The obstructed pancreatico-biliary drainage limb: presentation, management, and outcomes. J Gastrointest Surg. 2010;14(9):1414–21.

    Article  Google Scholar 

  19. Miller MT, Rovito PF. An approach to venous thromboembolism prophylaxis in laparoscopic roux-en-Y gastric bypass surgery. Obes Surg. 2004;14(6):731–7.

    Article  Google Scholar 

Download references


Not Applicable.


Not applicable.

Author information

Authors and Affiliations



Author 1: KB made substantial contributions to conception and design and has been involved in drafting the manuscript. Author 2: MB has been involved in revising the manuscript critically for important intellectual content. All authors read and approved the final manuscript.

Authors’ information

Kiran C Baran is currently resident burn medicine at the Burn Center Beverwijk, Red Cross Hospital Beverwijk. During the process of this case report, she was resident general surgery at Slotervaart Medical Center in Amsterdam.

Maurits de Brauw is currently bariatric and gastro-intestinal surgeon at Spaarne Gasthuis Hoofddorp. During the process of this case report, he worked at the Slotervaart Medical Center in Amsterdam.

Corresponding author

Correspondence to Kiran Chandni Baran.

Ethics declarations

Ethics approval and consent to participate

Not Applicable.

Consent for publication

Written informed consent was obtained from the participant on June 9th 2018, for publication of this article and any accompanying tables/images. A copy of the written consent is available for review by the Editor of this journal.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Baran, K.C., de Brauw, M. Pancreatitis following bariatric surgery. BMC Surg 19, 77 (2019).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: