Morbid obesity is increasing worldwide. In the US, in 2002, 5.1% of adults were considered to be morbidly obese, having a body mass index of 40 or higher.9
This resulted in an increase in the number of gastric bypass surgeries. In the US, 13 365 bariatric surgical procedures were performed in 1998, and this increased to 205 000 in 2007.1,10
Gastric bypass is considered the most common bariatric surgical procedure, accounting for about 88% of all surgeries performed for obesity.10
The increase in the number of bariatric gastric bypass procedures resulted in an increase in the number of postsurgical complications. One serious and challenging complication following Roux-en-Y gastric bypass is upper gastrointestinal bleeding. It is commonly the result of bleeding from marginal ulcers at the gastrojejunal anastomosis.11,12
This has been reported in as many as 7% of all patients who have had Roux-en-Y gastric bypass.11
Jamil et al, in a large series of 933 patients who underwent laparoscopic Roux-en-Y gastric bypass, reported a 3.2% incidence of postoperative upper gastrointestinal bleeding.12
All these patients were found to have bleeding from the gastrojejunostomy staple line. The diagnosis of this complication is not difficult with the aid of esophagogastroscopy. On the other hand, a peptic ulcer in the bypassed stomach in patients who have had a Roux-en-Y gastric bypass poses both diagnostic and therapeutic difficulties. It has been shown that the bypassed gastric segment retains its ability to secrete acid and respond to vagal and hormonal stimuli.13,14
The presence of other factors such as smoking, the use of NSAIDs, and H pylori
infection can contribute to the development of a peptic ulcer. Our patient had H pylori
isolated from the gastric pouch. This could have contributed to the development of the peptic ulcer in the excluded stomach. These ulcers are liable to develop complications such as bleeding and perforation.1,3
The diagnosis of bleeding duodenal and antral ulcers in patients who have had Roux-en-Y gastric bypass for morbid obesity is difficult. The main reason for this is the inaccessibility of the excluded stomach because of the altered anatomy. To obviate this, lifelong proton pump inhibitors have been advocated for all patients who undergo Roux-en-Y gastric bypass.15
The standard gastroscope is not long enough to reach the duodenum and stomach and therefore the use of longer endoscopes has also been suggested. Upper esophagogastroscopy is however valuable to exclude marginal ulcers at the jejunogastric anastomosis. This is also the case when using transcolonic endoscopes as they are not long enough to reach the Roux limbs. To overcome this, a variety of diagnostic and therapeutic procedures have been advocated.1–8
For example a Tc-99m RBC scan or a celiac angiogram can be used to localize the site of the upper gastrointestinal bleeding; the latter can also be used to stop the bleeding once identified. Other methods that have been used include CT scan, CT angiogram, endoscopy via percutaneous gastrostomy, and intraoperative endoscopy. The technique we have described is simple and is less invasive than a laparotomy. It proved valuable as a diagnostic and therapeutic procedure.
In conclusion, upper gastrointestinal bleeding in patients who have had Roux-en-Y gastric bypass for morbid obesity presents unique diagnostic and therapeutic challenges, both for the bariatric surgeons and gastroenterologists, because of difficulties in accessing the bypassed stomach endoscopically. Laparoscopic endoscopy is a feasible and valuable diagnostic and therapeutic procedure in these patients.