Small Bowel Perforation in Roux-en-Y Gastric Bypass (RYGB) Secondary to Apolipoprotein A-IV (AApoA-IV) Type...

ApoA-IV amyloidosis is a rare disease that involves the deposition of ApoA-IV protein aggregates in tissues. It commonly presents as cardiac or renal disease, but can, in rare cases, cause small bowel perforation.

This study describes a case of ApoA-IV type amyloidosis causing small bowel perforation after conversion of a sleeve gastrectomy (SG) into a RYGB in a Crohn's disease (CD) and rheumatoid arthritis (RA) patient. It also considers the indications for bariatric and anti-reflux surgery in the setting of co-morbid inflammatory bowel disease (IBD), gastro-oesophageal reflux disease (GORD), and obesity.

Obesity can reduce the efficacy of IBD medications and drives a pro-inflammatory state that may worsen IBD, however IBD patients present an operative challenge due to risk of more intestinal adhesions, potential intolerance to intestinal bypass, and risk of affecting options for future bowel resections if required. SG is often chosen over RYGB for CD patients due to limited short-term complications. However, when considering co-morbid GORD, the long-term risk of medication resistant GORD, erosive oesophagitis, and Barrett's oesophagus with SG is significant, especially given that SG is an irreversible procedure.

There is growing evidence that bariatric surgery in IBD patients is both safe and effective, however the decision to perform bariatric surgery in an IBD patient involves consideration of the intricate interplay between obesity and IBD.