Lahari Kota, MD1, Nazir Ahmed, MD2, Shawn Philip, DO2, Shil Patel, DO2 1Hackensack University Medical Center, Secaucus, NJ; 2Hackensack University Medical Center, Hackensack, NJ
Introduction: The Roux-en-Y gastric bypass (RYGB) is an increasingly common bariatric procedure in the current obesity epidemic. While beneficial, it has many known late stage complications. Here we describe a rare case of gastric remnant dilation secondary to a marginal ulcer with perigastric and perihepatic abscesses.
Case Description/Methods: An 80 year-old female with a history of obesity status-post laparoscopic RYGB in 2008 and an EGD proven bleeding marginal ulcer in 2023 presented to the ED with several weeks of increasing abdominal cramping, nausea, vomiting, odynophagia, and dysphagia to solids and liquids. She was afebrile, hemodynamically stable and without significant weight loss. The physical exam was significant for mild epigastric tenderness to palpation. Labs revealed WBC 11.8 x10^3/uL, Hgb 9.0 g/dL, MCV 72.2 fL, RDW 19.6%, INR 1.29, BUN 21 mg/dL. CT scan showed a distended, fluid-filled remnant stomach with a 12.9 cm saccular component causing mass effect on the liver (Figure 1). There was also a perigastric fluid collection with communication to a perihepatic collection (Figure 2). 1.4 L of purulent fluid was removed from the perihepatic collection via CT guided drainage and a percutaneous drain was placed. Aspirate was positive for E. Coli and P. Denticola and Zosyn therapy was initiated. Endoscopic evaluation revealed a healing jejunal ulcer overlying the peri-gastric collection (Figure 3). The remaining RYGB was unremarkable and without an obstruction. A 18mm Steris endoclip was applied. Repeat CT scan showed near complete resolution of the collections one week after drain placement. Drain was removed two weeks after placement and repeat CT scan one week later showed no recurrence (Figure 4).
Discussion: Marginal ulcers are rare late complications of RYGB that can occur at the gastrojejunal anastomoses and can present with further complications such as gastrogastric fistulas, obstructions, and perforations. This patient had a marginal ulcer that ruptured and sealed off with subsequent abscess formation and gastric remnant dilation which occurs in about 0.08% of cases. Although extremely rare, it is necessary to maintain high clinical suspicion for this pathologic process.
Figure: Figure 1: Dilated remnant stomach with air-fluid levels. Figure 2: Communicating perigastric and perihepatic fluid collections. Figure 3: Healing, non-bleeding jejunal ulcer. Figure 4: Follow up CT scan after discharge with thin linear fluid collection, stable from prior to drain removal.
Disclosures:
Lahari Kota indicated no relevant financial relationships.
Nazir Ahmed indicated no relevant financial relationships.
Shawn Philip indicated no relevant financial relationships.
Shil Patel indicated no relevant financial relationships.
Lahari Kota, MD1, Nazir Ahmed, MD2, Shawn Philip, DO2, Shil Patel, DO2. P1657 - A Rare Case of Roux-en-Y Marginal Ulcer Causing Massive Gastric Remnant Dilation and Abscesses, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.
