Overview
Definition:
A marginal ulcer is a late complication of gastric bypass surgery, occurring at the gastrojejunal anastomosis or the gastric pouch remnant
It is characterized by a full-thickness defect in the mucosa and submucosa of the gastrointestinal tract at the surgical connection.
Epidemiology:
The incidence of marginal ulcers after gastric bypass ranges from 0.6% to 17%, with some studies reporting higher rates
Risk factors include NSAID use, H
pylori infection, smoking, and stricture at the anastomosis
It typically presents between 6 months and 2 years post-operatively, but can occur earlier or later.
Clinical Significance:
Marginal ulcers can lead to significant morbidity, including bleeding, perforation, and obstruction, requiring urgent surgical intervention and impacting patient recovery and long-term outcomes
Accurate diagnosis and timely management are crucial for preventing life-threatening complications.
Clinical Presentation
Symptoms:
Epigastric pain, often burning or gnawing, that may be similar to pre-operative dyspepsia or related to food intake
Nausea and vomiting, especially after consuming solids
Early satiety
Bleeding, presenting as hematemesis or melena
Perforation, with sudden severe abdominal pain, rigidity, and signs of peritonitis
Obstruction, causing persistent vomiting and inability to tolerate oral intake.
Signs:
Tenderness in the epigastric region
Signs of anemia if bleeding is present (pallor, tachycardia)
Signs of peritonitis (rebound tenderness, guarding) if perforation has occurred
Distended abdomen and high-pitched bowel sounds if obstruction is present
Vital sign abnormalities may include tachycardia and hypotension in cases of significant bleeding or perforation.
Diagnostic Criteria:
Diagnosis is primarily based on clinical suspicion confirmed by upper gastrointestinal endoscopy
Endoscopic findings include erythema, erosions, and discrete ulcerations at the gastrojejunal anastomosis
Biopsies are taken to rule out malignancy and test for H
pylori
Radiographic evidence (e.g., contrast studies) may suggest but are not definitive for ulceration.
Diagnostic Approach
History Taking:
Detailed history of bariatric surgery type and date
Review of post-operative course, including any previous complications
Assessment of pain characteristics, timing, and relation to meals
Inquiry about NSAID use, smoking, and alcohol consumption
History of H
pylori infection
Assessment for signs of bleeding (melena, hematemesis) or obstruction (vomiting).
Physical Examination:
Thorough abdominal examination, assessing for tenderness, guarding, rebound tenderness, masses, and signs of distension
Examination for pallor and other signs of anemia
Evaluation of vital signs for hemodynamic stability.
Investigations:
Complete blood count (CBC) to assess for anemia and infection
Liver function tests (LFTs)
Renal function tests (RFTs)
Upper gastrointestinal endoscopy with biopsy for H
pylori testing and to rule out malignancy
Barium swallow or CT scan may be used to assess for complications like stricture or perforation, especially if endoscopy is not immediately available or conclusive.
Differential Diagnosis:
Peptic ulcer disease (non-anastomotic)
Gastritis
GERD
Gastric stasis
Marginal zone lymphoma
Anastomotic stricture without ulcer
Bile reflux gastritis.
Management
Initial Management:
Discontinuation of NSAIDs and offending agents
Aggressive proton pump inhibitor (PPI) therapy, typically intravenous initially
Nasogastric tube decompression if obstruction is suspected
Fluid resuscitation and correction of electrolyte imbalances
Blood transfusion if significant bleeding is present.
Medical Management:
High-dose PPI therapy (e.g., pantoprazole 40 mg IV twice daily, transitioning to oral)
Eradication therapy for H
pylori if positive, using a combination of PPI, bismuth, and two antibiotics (e.g., clarithromycin, amoxicillin, metronidazole) for 10-14 days
Sucralfate can be used as an adjunct
Smoking cessation counseling.
Surgical Management:
Surgical intervention is indicated for refractory ulcers, bleeding, perforation, or obstruction
Options include: Revision of anastomosis with ulcer excision and resuturing
Conversion to Roux-en-Y gastrojejunostomy if a loop bypass was performed
Resection of gastric pouch if the ulcer is in the remnant
In cases of perforation, emergency laparotomy with repair and possible pouch revision
Laparoscopic techniques are preferred when feasible, but conversion to open surgery may be necessary.
Supportive Care:
Nutritional support, including parenteral or enteral feeding if oral intake is compromised
Close monitoring of vital signs, pain, and output
Regular laboratory monitoring for anemia and electrolytes
Pain management
Education regarding lifestyle modifications.
Complications
Early Complications:
Hemorrhage, perforation, acute gastric outlet obstruction, anastomotic leak.
Late Complications:
Chronic pain, stricture formation, internal herniation (rarely related directly to ulcer but co-existing), malnutrition, vitamin deficiencies
Recurrence of ulceration.
Prevention Strategies:
Meticulous surgical technique to create a tension-free anastomosis
Avoidance of NSAIDs and smoking
Screening and eradication of H
pylori pre-operatively
Liberal use of PPIs post-operatively, especially in high-risk patients
Patient education on lifestyle modifications and medication adherence.
Prognosis
Factors Affecting Prognosis:
Promptness of diagnosis and initiation of treatment
Severity of ulceration and presence of complications (bleeding, perforation, obstruction)
Patient comorbidities
Adherence to medical and lifestyle recommendations
Successful surgical revision if indicated.
Outcomes:
With appropriate medical and surgical management, most marginal ulcers can be healed
However, recurrence is possible
Outcomes are generally good for uncomplicated ulcers treated medically
Complicated ulcers requiring surgery have higher morbidity and longer recovery periods.
Follow Up:
Long-term follow-up with a bariatric surgery team is essential
Regular endoscopic surveillance may be recommended, particularly for patients with a history of ulcers or ongoing risk factors
Continued PPI use may be necessary for some patients
Dietary and lifestyle counseling.
Key Points
Exam Focus:
Marginal ulcers occur at the gastrojejunal anastomosis post-GBP
Key symptoms mimic pre-op dyspepsia but can include bleeding or obstruction
Diagnosis is by endoscopy
Management involves PPIs, H
pylori eradication, and surgical revision for refractory/complicated cases
NSAIDs and smoking are major risk factors.
Clinical Pearls:
Always consider marginal ulcer in patients with post-GBP epigastric pain or new-onset dyspepsia
Endoscopy is the gold standard
Early surgical intervention for perforation or severe bleeding is life-saving
Lifestyle modification is critical for prevention and management.
Common Mistakes:
Attributing all post-GBP epigastric pain to "dumping syndrome" without considering marginal ulcer
Delaying endoscopy in patients with concerning symptoms
Inadequate PPI dosage or duration
Failure to screen for and eradicate H
pylori
Ignoring the role of NSAIDs and smoking.