Obstruction of the excluded stomach (afferent or hepatobiliary limb) due to a biopsy-proven pyloric adenocarcinoma. This case requires careful reporting and clear communication that the alimentary limb is open (and thus an NG tube will not help), as delays in decompressing an obstructed afferent limb can result in ischemia and poor outcomes. 

In this case, interventional radiology placed a percutaneous pigtail catheter through the stomach to decompress the intraluminal contents. The tissue diagnosis of adenocarcinoma was obtained using ultrasound-guided biopsy, with a relatively straightforward acoustic window for percutaneous biopsy. 

While cases like this require you to think outside of the box and gastric adenocarcinoma is most commonly diagnosed endoscopically, the use of a percutaneous ultrasound guided approach provides an elegant solution to the problem of obtaining tissue in this bypass patient rather than proceeding with open biopsy.