A multihit cascade of late complications after Roux-en-Y gastric bypass leading to refractory malnutrition: a case report.

INTRODUCTION AND IMPORTANCE: Roux-en-Y gastric bypass (RYGB) is an effective metabolic procedure with durable weight loss and metabolic benefits. However, catastrophic late-onset malnutrition is rarely reported, particularly when multiple long-term complications interact sequentially. We present a case illustrating a multihit cascade of skeletal and gastrointestinal events culminating in life-threatening refractory malnutrition long after RYGB. PRESENTATION OF CASE: A 67-year-old woman with a history of RYGB for severe obesity developed an osteoporosis-related fragility fracture, followed by prolonged immobilization. During subsequent hospitalization, she experienced stress- and medication-induced marginal ulceration, complicated by perforation and prolonged fasting. These events collectively precipitated profound macro- and micronutrient deficiencies that were refractory to conventional oral and parenteral supplementation. The patient was managed with intensive nutritional rehabilitation, including combined enteral feeding via the oral route and a feeding gastrostomy, alongside parenteral nutritional support. Recovery was markedly protracted, underscoring the severity and refractoriness of the nutritional derangement. CLINICAL DISCUSSION: This case demonstrates that patients who have undergone RYGB remain vulnerable to delayed, synergistic complications arising from altered gastrointestinal anatomy, impaired absorptive capacity, chronic acid suppression, and age-related physiological decline, which can culminate in catastrophic malnutrition years to decades after surgery. CONCLUSION: Increased awareness among general clinicians, particularly during hospitalizations for unrelated medical conditions, together with lifelong nutritional surveillance, early multidisciplinary involvement, and timely referral to bariatric specialists is essential to prevent irreversible nutritional deterioration in long-term survivors of bariatric surgery.