Carmen Tugulan, MD, Christopher Mellon, DO, Keng-Yu Chuang, MD, Paul Anthony R Del Prado, MD. Maricopa Integrated Health System
This is a case of a 37 year old male with a previous history of a redo-hiatal hernia 5 years prior who presented with two episodes of upper gastrointestinal bleeding with no identifiable source noted on both endoscopy and angiography. During his second admission, initial hemoglobin was 5.5 g/dL and endoscopy performed showed massive amount of blood in the stomach. Continuous oozing was seen originating in the fundus area but no clear source could be identified. Empiric epinephrine was injected to the area but failed to achieve hemostasis. Angiography was also negative. Repeat endoscopy performed showed no active bleeding, however, distention of the wrap into the gastric cavity was observed. The patient re-bled and was taken to the operating room emergently after failed attempt at endoscopic control. The patient underwent proximal gastrectomy after intra-operative gastrostomy and exploration was unable to identify a bleeding source. The patient was left with an open abdomen and in discontinuity while resuscitation was performed in the surgical intensive care unit. He subsequently underwent a Roux-en-Y reconstruction and gastrostomy tube placement via the distal gastric remnant. Upper gastrointestinal series performed demonstrated absence of leak, and the patient was started on a liquid diet supplemented with tube feeding. His recovery was uneventful and he was discharged home in stable condition.
Pathology revealed gastric ischemia at the base of the wrap making it impossible to visualize through endoscopy. On reviewing the literature, gastric ulcers and ischemia have been previously described. Incidence was up to 3% and their onset of presentation ranged from the early post-operative period up to 5 years. Most were located in the lesser curvature. The exact pathophysiology for its occurrence is not completely understood. Factors hypothesized include technical aspect of the fundoplication causing inappropriate tension, vessel disruption and ischemia, and injury to the vagus nerve affecting gastric emptying which was thought to increase gastrin secretion.
Treatment includes medical management with proton pump inhibitors; however, few cases describe antrectomy with inclusion of the bleeding ulcer. Our case presents failed medical and endoscopic management. We recommend take down of the fundoplication in hemodynamically stable patients to completely evaluate the gastric mucosa, identify, and address the source of bleeding. Otherwise emergent cases will require staged gastrectomy including the wrap followed by Roux-en-Y reconstruction.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 88095
Program Number: P159
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster