Understanding Small Bowel Obstruction - A Rare Complication of Bariatric Surgery

The unexpected death of Lisa Marie Presley last January has been linked to a complication of years-old bariatric, or weight loss, surgery, according to an autopsy report. 

The singer-songwriter and daughter of Elvis Presley suffered cardiac arrest at the time of her death, but the true cause of death has now been deemed sequelae—or the after-effects—of a small bowel obstruction. 

A small bowel obstruction is a rare but serious condition where the bowel becomes blocked in some way. The blockage usually has two effects, said Jonathan Schoen, MD, associate professor of surgery and medical director of the surgical weight loss center at the University of Colorado School of Medicine.

“Whatever is passing through the small intestine—such as food and bile and liquids—gets blocked from passage,” he told Health. “depending on the type of blockage, the blood supply to the small intestine can be put in jeopardy.”

If the blockage is caught in time it can usually be treated, Schoen explained. But if a person lets the issue progress, the situation can become life-threatening. This is likely what happened with Presley.

Prior to her death, Presley had been experiencing constipation and a distended abdomen for years, and abdominal pain, fevers, and vomiting for months. According to the autopsy, she did not seek medical care.

Presley had been prescribed pain medications for a cosmetic procedure that happened a few months earlier. Those may have diluted her pain, so Presley didn’t know how serious her pain truly was, Sajani Shah, MD, chief of bariatric surgery at Tufts Medical Center, suggested.

Here’s what experts had to say about how small bowel obstructions are related to weight loss surgeries, and the signs that might indicate something is wrong.

Weight loss surgeries are considered safe and effective. For instance, people who get gastric bypass surgery have about a 1% chance of experiencing small bowel obstruction over the course of a lifetime, Shah explained. Schoen put it between 2% and 3%.

Again, typically small bowel obstructions don’t progress to a deadly point. But there are actually a number of ways that old surgeries can sometimes come back to cause issues. 

For one, the small bowel, or intestine, can actually be blocked from outside the organ. In Presley’s case, her obstruction was caused by scar tissue from a weight loss surgery years ago, according to the autopsy report.

“There’s something that we call an adhesion—or scar tissue from having previous surgery—that can form these bands that kink the bowel from the outside,” Shah told Health. 

Those kinks can then prevent things from moving through the small bowel, Schoen explained, and can even cut off blood flow.

Another way to visualize it is to think about the bowel as a long, thin balloon, Brooks Cash, MD, a professor of medicine, told Health.

Inflammation and scar tissue from previous surgeries can cause issues when the bowels move.

“There can be a point where the bowel sticks,” Cash, who serves as the chief of the division of gastroenterology at the University of Texas Health Science Center at Houston and McGovern Medical School, said. “But the remainder of the bowel around that point continues to move. And it can twist on itself and become very much like one of those balloon art conditions.”

The small bowel can also be blocked internally by a mass, such as a tumor, Shah said. 

And gastric bypass surgery—one of the most common forms of weight loss surgery—can have some other internal blockage risks associated with it.

After gastric bypass surgery, people can develop strictures, which means that the newly made connection between the stomach and small bowel is too narrow. Internal hernias, or pockets where the bowel gets stuck, are another concern.

Because these patients have portions of their stomachs that aren’t in use anymore, “things back up” quickly, Shah said. This could raise the risk of small bowel obstruction becoming more dangerous. 

But regardless of whether they stem from an internal or external source, like Presley’s, small bowel obstructions are especially insidious because they can bubble up months or even years after a weight loss surgery is complete. 

“There is no timeline for small bowel obstructions after surgical procedures—they can happen anytime,” Cash said. Even though they’re not common, he explained, “there is no way to predict them. There’s really no way to prevent them.”

With the risk of small bowel obstructions lingering for possibly years after a procedure, it’s crucial that people who’ve gotten any abdominal surgery keep on the lookout for any possible signs of the complication. 

'Nausea, vomiting,  crampy abdominal pain should take you to seek medical attention earlier rather than later,” Schoen said. 

Delaying care—whether it be because patients don’t have access to care or simply don’t think their symptoms are severe enough—just makes the situation worse, Cash said. 

The condition would have to progress quite significantly to get to a point where it's deadly. But it’s possible that even the cardiac arrest Presley suffered may have been related to her bowel obstruction.

“The two can be connected,” Schoen said. “Let’s say there was a perforation of the small intestine, or a segment of the small intestine died from lack of blood flow. Then that person can get very sick, develop sepsis, and lead to cardiopulmonary arrest.”

Presley’s story is certainly an outlier—people who’ve had abdominal surgery in the past shouldn’t be afraid, Cash explained. But it is important that people pay attention to their symptoms, and seek care if they think they may need it.

“The key to these is making the diagnosis fairly quickly and then repairing the problem expeditiously,” said Schoen. “And then most problems related to it can be prevented.”