Bleeding duodenal ulcer after Roux-en-Y gastric bypass surgery: the value of laparoscopic gastroduodenoscopy

Abstract

Roux-en-Y gastric bypass is a common surgical procedure used to treat patients with morbid obesity. One of the rare, but potentially fatal complications of gastric bypass is upper gastrointestinal bleeding, which can pose diagnostic and therapeutic dilemmas. This report describes a 39-year-old male with morbid obesity who underwent a Roux-en-Y gastric bypass. Three months postoperatively, he sustained repeated and severe upper attacks of upper gastrointestinal bleeding. He received multiple blood transfusions, and had repeated upper and lower endoscopies with no diagnostic yield. Finally, he underwent laparoscopic endoscopy which revealed a bleeding duodenal ulcer. About 5 ml of saline with adrenaline was injected, followed by electrocoagulation to seal the overlying cleft and blood vessel. He was also treated with a course of a proton pump inhibitor and given treatment for H pylori eradication with no further attacks of bleeding. Taking in consideration the difficulties in accessing the bypassed stomach endoscopically, laparoscopic endoscopy is a feasible and valuable diagnostic and therapeutic procedure in patients who had gastric bypass.

Bridged Mini Gastric Bypass: A Novel Metabolic and Bariatric Operation

“…In these cases, there is no endoscopic way to reach the remnant stomach in case of upper GI bleeding and laparoscopic endoscopy is mandatory in the operating theatre, under general anesthesia. 16,17 The same risk is present for MGB. In the modified technique that we described, the remnant stomach can be reached through the artificial GGF.…”

Perforation of the gastric remnant in a patient post-Roux-en-Y gastric bypass

“…In the latter, a gastrostomy is created and a scope is guided laparoscopically in the stomach and the duodenum 9. Unfortunately, in our patient, multiple efforts with double balloon enteroscopy in a specialised referral centre were unable to reach the excluded stomach.…”

Gastrointestinal bleeding from the excluded stomach: a proposed algorithmic approach to management

“…Other rare causes, such as in this case, are due to peptic ulceration in the excluded structures [6,[8][9][10]. Studies conducted on animals and humans have shown decreased acid production within the new gastric pouch, but there was maintenance of acid secretion in the excluded bowel and gastric remnant favoring the development of ulcers [11][12][13].…”