The patient had a Roux en Y gastric bypass two years ago and had presented to an outside hospital for increasing abdominal pain. The patient was evaluated in the ER and was evaluated with a CT scan which was read as normal with no obstruction. General Surgery was consulted and felt patient would be appropriate for a medical floor bed. Patient was admitted to the medicine service with presumed diagnosis of marginal ulcer, placed on PPI and pain medications and GI medicine consult was obtained. Gastroenterology agreed with PPI's and schdeuled pt for outpatient endoscopy after discharge. Over the weekend patient's pain medications were escalated and on Monday morning patient begged his attending physician and stated " this amount of pain cannot be normal". The attending physician arranged for an inpatient endoscopy, Endoscopy revealed a necrotic roux limb. The patient was then transferred emergently to a nearby hospital that had a Bariatric Surgeon who emergently explored the patient and found necrotic bowel from an internal hernia with volvulus and resected bowel and refashioned the gj and recreated a jejunojejunostomy. Patient was left with 200 cm of total small bowel length with a 50 cm roux limb. Over the next several months patient had tremendous diarrhea and was treated with antidiarrheal agents, gatex and enteral supplementation. When pt was referred to us his albumin was 1.2 with anasarca. for 3 months he was given TPN and when his albumin was 2.8 we took him for a reversal.