Kairo Noronha, BS1, Syed-Mohammed Jafri, MD2 1Wayne State School of Medicine, Detroit, MI; 2Henry Ford Health, Detroit, MI
Introduction: Ulceration is an uncommon complication of gastric bypass and is generally managed with proton pump inhibitor therapy with resolution. We present a case of refractory abdominal pain and poor oral intake associated with the development of a severe marginal ulcer following Roux-en-Y gastric bypass surgery with failed medication therapy.
Case Description/Methods: A 29-year-old female with a history of gastroesophageal reflux and obesity presents with burning abdominal pain in the epigastric region, occurring primarily after meals. She is initially prescribed several proton pump inhibitors and H2 blockers without effect. She undergoes an esophagogastroduodenoscopy (EGD) and 24hr pH impedance, revealing reflux, mild erythema of the lower esophagus, and chronic gastritis. She has an unremarkable barium swallow and esophageal manometry. She has a successful Roux-en-Y gastric bypass and is symptom free for a few months while also losing thirty pounds. However, she again begins experiencing oral intolerance and progressive abdominal pain, resulting in malnutrition and dehydration. An EGD is performed, and a large cratered marginal ulcer is found at the surgical site of her gastrojejunostomy. She is prescribed omeprazole and sucralfate to remedy the ulcer. Eight weeks later, a repeat EGD is performed, and the marginal ulcer is identified on the jejunal side of her gastrojejunostomy, meaning the medication treatment failed to heal the gastric ulcer. She is admitted for total parenteral nutrition to address her poor nutritional status, and upon improvement, she undergoes resection of the marginal ulcer and revision of her gastrojejunostomy. Apart from a right lower-quadrant abdominal wall port site abscess, which was fixed through an incision and drainage, she did not experience any complications with the procedure. Two months after surgery, she is able to tolerate diet without the use of supplemental nutrition, and she has not experienced any symptoms of nausea, vomiting, or abdominal pain.
Discussion: Nissen Fundoplication remains the gold standard procedure for patients with severe acid reflux. For obese subset of patients, Roux-en-Y gastric bypass is preferred. Marginal ulcers are an uncommon complication for Roux-en-Y gastric bypass surgeries with an incidence rate of 1-5%. The majority of these cases are remedied with medication therapy. If medical management is unsuccessful, resection of the ulcer and revision of the gastrojejunostomy may be appropriate.
Disclosures:
Kairo Noronha indicated no relevant financial relationships.
