Background

Chronic mesenteric ischemia is most often caused by atherosclerotic disease at the origin of the mesenteric arteries. Typically, it involves two of the three vessels, classically presenting as postprandial abdominal pain manifesting in food fear and weight loss. We report the case of a 64-year-old patient who underwent Roux-en-Y gastric bypass (RYGB) in 2011. In 2021, she developed intermittent abdominal pain, vomiting, and weight loss, with EGD revealing marginal ulceration at her gastrojejunostomy as well as ulcerations more distally within the Roux limb. On further evaluation, it was discovered that prior to bariatric follow up at our institution, this patient was diagnosed with chronic mesenteric ischemia in 2016 secondary to superior mesenteric artery (SMA) stenosis and had undergone multiple angioplasties. Each intervention improved her symptoms for some time prior to redeveloping stenosis and subsequent pain. Eventually she occluded her SMA, but given adequate collateralization from the celiac artery, vascular surgery planned not to intervene again. Her pain worsened, which led to EGD and diagnosis of Roux limb ulceration in 2021. Eventual follow up with our bariatric surgeons led to the realization and ensuing conversation that the sole blood supply to the Roux limb is the SMA, and it cannot rely on collateralization from the celiac artery. In short, in patients with recurrent Roux limb ulceration without other risk factors, chronic mesenteric ischemia must be considered as a potential etiology; furthermore, patients may require repeat interventions on this vessel in order to prevent severe complications.