Key clinical messageOne of the most frequent and problematic long-term complications after a Roux-en-Y gastric bypass is internal hernia that can present with or without small bowel obstruction (SBO).1 Its incidence can be reduced in the short term by closing the mesenterial defect but is still a concern specially in the long term.2 This case shows the acute presentation and severe implications of an internal hernia with small bowel obstruction after a Roux-en-Y gastric bypass as well as its management.KeywordsBariatric surgery, internal hernia, Small bowel obstruction post-gastric bypassCase presentationA 33-year-old patient with surgical history of robotic assisted Roux-en-Y gastric bypass for the treatment of morbid obesity, presented to the emergency department with acute abdominal pain, nausea, vomiting, tachycardia and hypotension. Abdominal CT scan showed a large, distended remnant of the stomach and distended duodenum compatible with a closed loop obstruction at the jejunostomy, most probably an internal hernia or volvulus (Figure 1). NGT was placed with not much output. Interventional radiology placed a percutaneous gastrostomy tube decompressing the remnant stomach achieving 3 liters of bilious output. Important to mention is a delayed in intervention occurred, as surgery was not consulted immediately.