A potentially dangerous complication is jejunal obstruction (biliopancreatic tract), since this obstruction does not present a typical clinical picture of intestinal obstruction. This diagnosis should always be considered in patients with relatively acute abdominal colic-type pain. An erect plain abdominal film does not show conventional air-fluid levels, occasionally part of the abdomen may be grey. The diagnosis can only be confirmed by ultrasound investigation or a CT scan of the abdomen, which will reveal clearly dilated intestinal loops filled with fluid only. In some cases a dilated duodenum is also visible. This obstruction is potentially dangerous because pancreatitis can be induced by overpressure in the duodenum.

Anaemia.
Gastrectomy with exclusion of the jejunum is responsible for this possible complication.
Exclusion of the chief sight of iron absorption is the cause of relative iron malabsorption.
Less frequently, anaemia can be caused by folic acid deficit and rarely by vitamin B12 deficiency.
Anaemia occurs only in patients with chronic physiological (menstruation) or pathological (haemorrhoids, stoma ulcer) loss of blood. Depending on the cause, the anaemia is usually microcytic, less frequently normocytic and only now and again macrocytic.
The general incidence of anaemia is 35% (25% in my personal series), but periodic iron, folic acid or vitamin B12 supplements can reduce the frequency to less than 5%. As time goes by, fewer supplements are required.

Stoma-ulcer.
The incidence with a minimal follow-up of 2 years is 6.9% and is strongly influenced by alcohol and smoking behaviour in particular. The incidence of ulcers increases from 2% in the case of double abstinence to 17.1% in patients who drink and smoke, to even 25.8% in patients who consume alcohol and smoke over 40 cigarettes daily.
Most ulcers (67%) appear in the first postoperative year and the remainder in the next year. They usually respond well to conservative treatment (94% cure rate with H2-blockers) and rarely recur in patients who have stopped smoking (12.5% recurrence in the event of smoking cessation compared to 30.7% in patients who continue to smoke).
 
Hypoproteinaemia.
Hypoproteinaemia, in particular hypoalbuminaemia, is the most severe complication of BPD. It may be associated with anaemia, oedema, asthenia and hair loss. In some cases readmission may be necessary for TPN (total parenteral nutrition). In most cases, there is a single episode in the first and occasionally the second postoperative year, occurring in particular after a prolonged period of diarrhoea or reduced food intake.
Hypoproteinaemia occurred in less than 10% of the cases in our group.
This complication emphasizes the importance of regular laboratory investigations in the first two postoperative years.
In the event of a serious drop, treatment can be started immediately with medication such as in Creon,
2 to 3 capsules per meal, in rare cases 10 capsules or more daily. In general a period of a few months, until the intestine has further adapted, is sufficient.
In the event of recurring hypoproteinaemia the common limb can be elongated by 1 meter (less than 4%). In less than 1% complete restoration of the transit is necessary.
Patient cooperation, with regular controlled food intake, a diet high in protein, and fat restriction in the case of diarrhoea play an important role in the prevention of this complication.

Peripheral neuropathy.  
This is an extremely rare early complication that is due to a marked lack of food intake. It can easily be prevented by administration of thiamine (vitamin B1) in patients with a very limited food intake during the first weeks.

Bone demineralization.
All our patients are advised to take minimum 1 gram Calcium per day (only a minority follows this advice), since Calcium is better absorbed in the excluded part of the tract, in particular the duodenum and the proximal part of the jejunum.
Another cause of bone demineralization may be a lack of vitamin D, which can result in bone pain (osteomalacia). Vitamin D is a liposoluble vitamin and is therefore less well absorbed in these patients. In our group of patients we noted a reduction of 25 OH vitamin D in 9% of the cases. Oral vitamin D (D-cure 1 to 3 ampoules per week) for a few months is generally sufficient to cure this hypovitaminosis. If the response is insufficient, Dedrogyl drops 3 x 10 to 15 drops per meal are administered. Only a few patients who failed to attend follow-up visits, developed osteomalacia. In exceptional cases this resulted in spontaneous rib fractures.
These problems all occur mainly in the first 4 postoperative years and apparently disappear later.