Ulcer Disease in the Excluded Segments after Roux-en-Y Gastric Bypass: a Current Review of the Literature

Abstract

Ulcer disease in excluded segments after Roux-Y gastric bypass (RYGB) is rare but can evolve into a life-threatening situation. The excluded segments exhibit a different behavior from that of non-altered anatomy; perforated ulcers do not result in pneumoperitoneum or free fluid, and therefore must be met with a low threshold for surgical exploration. The anatomical changes after RYGB impede routine access to the remnant stomach and duodenum. There are various options to address bleeding or perforated ulcers. While oversewing and drainage preserves the anatomy and forgoes resection, remnant gastrectomy offers a definitive solution. The importance of traditional risk factors such as smoking or use of non-steroidal anti-inflammatory drugs is unclear. Eradication of Helicobacter pylori and secondary prophylaxis with proton-pump inhibitors is advisable, albeit in double-dose.

Bile Leak following Laparoscopic Cholecystectomy due to Perforated Duodenal Ulcer in Patient with Roux-en-Y Gastric Bypass

“…While the incidence of PUD after RYGB is not known, a recent review of the literature by Plitzko et al summarized a total of 54 patients from 5 case series and 18 case reports [ 3 ]. Of these reported cases, 28% of patients presented with gastrointestinal bleeding and 70% of patients presented with perforated ulcers [ 3 ].…”

“…While the incidence of PUD after RYGB is not known, a recent review of the literature by Plitzko et al summarized a total of 54 patients from 5 case series and 18 case reports [ 3 ]. Of these reported cases, 28% of patients presented with gastrointestinal bleeding and 70% of patients presented with perforated ulcers [ 3 ]. The site of bleeding occurred 53% in the remnant stomach and 47% in the remnant duodenum, whereas perforation was localized to the remnant stomach in 34% of cases and in the remnant duodenum 66% of cases [ 3 ].…”

“…Of these reported cases, 28% of patients presented with gastrointestinal bleeding and 70% of patients presented with perforated ulcers [ 3 ]. The site of bleeding occurred 53% in the remnant stomach and 47% in the remnant duodenum, whereas perforation was localized to the remnant stomach in 34% of cases and in the remnant duodenum 66% of cases [ 3 ]. The leading symptom at presentation was epigastric or upper abdominal pain, although bleeding, melena, weakness, and anemia were also common findings [ 3 ].…”

“…Mucosal injury may also result from the ingestion of NSAIDs or alcohol consumption [ 2 ]. After RYGB, there is continued but diminished acid excretion in the excluded stomach [ 3 ]. Gastrin levels are decreased, yet gastric mucosa maintains the ability to respond to vagal and hormonal stimuli, thus preserving an acidic environment [ 2 , 3 ].…”

“…This disease remains more prevalent in patients with known risk factors including the use of nonsteroidal anti-inflammatory drugs (NSAIDs), cigarette smoking, alcohol consumption, H. pylori infection, and hypersecretory states such as the Zollinger-Ellison syndrome [ 1 ]. Ulcer disease in the excluded segment after Roux-en-Y gastric bypass is a rare but potentially life-threatening complication with only 54 cases reported in the literature [ 2 , 3 ]. The anatomical changes after RYGB lead to an atypical clinical presentation and can be a diagnostic challenge.…”