Madalyn Morse, DO, Mukund Srinivas, BS, Joon K Shim, MD, MPH, FACS. Wright State University Boonshoft School of Medicine
INTRODUCTION: The differential diagnosis for abdominal pain after gastric bypass include dietary disorders, functional disorders, biliary disorders as well as pouch and remnant stomach disorders. With regards to small intestine disorders, the usual culprits are hernias, adhesions, stenosis, and intussusception. We describe a rare case of a patient with ulcerative roux limb jejunitis.
CASE DESCRIPTION: A 48 year old female with asthma, diabetes mellitus, fibromyalgia, hypertension and roux-en-y gastric bypass in 2005 for weight loss presented to our hospital with one week history of abdominal pain, vomiting and poor oral intake. At that time, she reported one episode of dark colored stool with admission hemoglobin of 8.2 with known chronic iron deficient anemia. She endorsed recent heavy NSAID use to control her fibromyalgia discomfort. Patient was not on home proton pump inhibitors or H2 blockers after her gastric bypass. Inpatient upper endoscopy showed erosive pouchitis and moderately severe jejunitis thirty centimeters from the gastrojejunal anastomosis in the mid-jejunal roux limb. Biopsies taken at that time demonstrated acute ulceration of jejunum and patchy/non-specific gastritis. Patient was recommended to discontinue NSAID use and begin twice daily proton pump inhibitor treatment. Helicobacter pylori testing was negative during admission. Hemoglobin remained stable.
DISCUSSION: Roux-en-y gastric bypass is associated with risk of several postoperative complications including malnutrition, GERD, internal hernia, anastomotic leak and marginal ulceration. There are several hypothesized causes of marginal ulceration post-RYGB including pouch size, orientation, staple line integrity, mucosal ischemia secondary to tension, NSAIDs, helicobacter pylori and smoking. Although several sources site jejunitis in post-RYGB patients, there are minimal reports of ulcerations thirty centimeters distal to the gastrojejunal anastomosis in the roux limb. Our patient’s ulcer was attributed to her heavy NSAID use for fibromyalgia. Although not yet a standard of care, it is not an uncommon practice for patients to be placed on long-term acid-suppression therapy with proton-pump inhibitors to mitigate this risk. Our patient was not on long term PPI use at time of her jejunal limb ulcer diagnosis.
CONCLUSION: Marginal ulcers at the gastrojejunal anastomoses are well known post-operative complication of RYGB as well as asymptomatic jejunitis of the roux-limb. Patients with increased risk factors including heavy NSAID use and smoking are also at risk for jejunal ulceration up to 30 centimeters from the GJ anastomosis as demonstrated by our patient case. Long-term PPI suppression therapy for post-RYGB patients should be considered in those at high risk for ulcers.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 85659
Program Number: P146
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster