The sleeve gastrectomy is an established procedure for the treatment of obesity, with the nutritional impacts and dietary management principles being well described in the literature. How do we realign these principles when the patient has anorexia nervosa? An 18 year old woman with a BMI of 14 presented to the Austin with acute gastric dilatation. With the suspicion of gastric ischaemia she was urgently taken to theatre where a large portion of stomach was frankly necrotic. Only the stomach along the lesser curvature and antrum was viable. A gastrectomy fashioned as a sleeve gastrectomy was the only way to maximize stomach preservation. She had an uncomplicated immediate post-operative course. Her early progress at 6 months and the nutritional issues that follow will be discussed.