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

Two case reports of acute upper gastrointestinal bleeding from duodenal ulcers after Roux-en-Y gastric bypass surgery: Endoscopic diagnosis and therapy by single balloon or push enteroscopy after missed diagnosis by standard esophagogastroduodenoscopy

“…Anastomotic ulcers are a common, important cause of UGI bleeding after RYGB, which most commonly occur in patients actively smoking or taking NSAIDs[ 9 ]. Such ulcers are usually easily detected and readily treated at EGD[ 10 ].…”

“…There are no standard recommendations in RYGB patients who present with obscure GI bleeding. Eid et al[ 9 ] recommended that examination of the bypassed stomach and duodenum should be attempted before performing colonoscopy to evaluate for a lower GI source and before performing capsule endoscopy to evaluate for a small bowel source. This work adds to the literature by suggesting the diagnostic and therapeutic benefits of push enteroscopy or single balloon enteroscopy if EGD was non-diagnostic and the excluded segments were not intubated at EGD in patients status post RYGB surgery (Figure 4 ).…”

“…Angiography with embolization should be considered in actively bleeding and hemodynamically unstable patients. Emergency surgery, possibly including resection of the bypassed stomach, should be considered for patients with refractory bleeding, but such surgery without prior endoscopic localization of the bleeding site increases the surgical failure rate[ 9 ]. Some authorities even suggest resection of the excluded stomach, which can be performed during the initial bypass surgery[ 21 ].…”

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

“…Thus, other factors might have a higher impact on ulcer formation. [11] 0/2 36 3 n/a Y n/a 54 0.2 n/a n/a n/a Bjorkman [12] 0/1 24 6 n/a N n/a Braley [13] 2/1 49 17 n/a n/a n/a 59 17 n/a n/a n/a 49 16 n/a n/a n/a Dai [9] 1 / 0 5 4 5 N N n e g Eid [14] 0/1 61 10 N N n/a Gypen [15] 1/0 35 0.2 n/a n/a pos Husain [16] 1/0 63 1.5 n/a n/a n/a Iranmannesh [28] 4 [24] 0/1 48 4 n/a n/a n/a Zagzag [27] 5/0 57 5 n/a n/a pos 54 12 n/a n/a pos 53 9 n/a n/a neg 47 0.7 n/a n/a n/a…”

“…Mesenteric angiography without previous CT angiography was performed in 25% of patients, and angiography showed active bleeding in 67% of patients. One patient had successful embolization, whereas embolization failed in the other patient, and surgical intervention was needed to control bleeding [14,25].…”