Overview
Definition:
Marginal ulcer resection refers to the surgical removal of an ulcer that forms at the gastrojejunal anastomosis, typically occurring after Roux-en-Y gastric bypass (RYGB)
These ulcers are a common complication, often presenting with significant morbidity.
Epidemiology:
The incidence of marginal ulcers after RYGB ranges from 1% to 16% in various studies, with a higher risk in the first year post-operatively
Factors like NSAID use, Helicobacter pylori infection, and anastomotic technique contribute to their development.
Clinical Significance:
Marginal ulcers can lead to severe pain, bleeding, perforation, and stricture formation, necessitating prompt diagnosis and management
Understanding the surgical approach for resection is critical for bariatric surgeons and residents preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Epigastric pain, often burning or gnawing
Nausea and vomiting
Early satiety
Hematemesis or melena, indicating bleeding
Symptoms may mimic dumping syndrome or GERD.
Signs:
Tenderness on epigastric palpation
Signs of anemia (pallor, tachycardia) if significant bleeding
Signs of perforation (peritonitis, rigidity) are rare but critical.
Diagnostic Criteria:
Diagnosis is primarily confirmed by upper endoscopy (EGD) revealing an ulcer at the gastrojejunal anastomosis
Biopsies should be taken to rule out malignancy and assess for H
pylori
Imaging like barium studies can show stenosis or free air if perforated.
Diagnostic Approach
History Taking:
Detailed history of pain characteristics, onset, and relieving/exacerbating factors
Prior NSAID or steroid use
History of H
pylori infection
Previous endoscopic findings
Symptoms suggestive of bleeding or obstruction.
Physical Examination:
Focus on abdominal examination for tenderness, masses, and signs of peritonitis
Assess for pallor and vital signs to detect hemodynamic instability due to bleeding.
Investigations:
Upper endoscopy (EGD) is the gold standard for diagnosis and allows for biopsy and biopsy-guided therapy
CBC for anemia
H
pylori testing (breath test, stool antigen, or biopsy)
Barium swallow if obstruction is suspected
CT scan if perforation is a concern.
Differential Diagnosis:
Peptic ulcer disease (gastric or duodenal), gastroesophageal reflux disease (GERD), gastritis, stomal stenosis, bezoar, internal hernia, malignancy at the anastomosis.
Management
Initial Management:
Medical management is the first line for uncomplicated ulcers
Proton pump inhibitors (PPIs) are crucial
Discontinuation of NSAIDs and treatment of H
pylori infection are essential
Nutritional support and fluid management if vomiting or bleeding is present.
Medical Management:
High-dose PPI therapy (e.g., omeprazole 40 mg BID, pantoprazole 40 mg BID) for at least 8-12 weeks
Eradication of H
pylori if positive, using triple or quadruple therapy regimens
H2 blockers may be used as adjuncts in some cases.
Surgical Management:
Surgical resection is indicated for refractory ulcers, bleeding, perforation, or significant stenosis
The procedure typically involves division of the gastrojejunal anastomosis and reconstruction
Techniques may include a single-layer or double-layer closure of the staple line and a new gastrojejunal or duodenojejunal anastomosis.
Supportive Care:
Close monitoring of vital signs and fluid balance
Blood transfusions if anemic from bleeding
Nutritional counseling regarding diet and avoidance of aggravating factors
Long-term follow-up with regular endoscopies to monitor for recurrence.
Complications
Early Complications:
Anastomotic leak, bleeding from the staple line, bowel obstruction, intra-abdominal abscess
These are generally related to the surgical revision itself.
Late Complications:
Ulcer recurrence, stricture formation at the new anastomosis, weight regain, nutritional deficiencies (e.g., iron, B12).
Prevention Strategies:
Strict adherence to post-operative dietary guidelines
Judicious use of NSAIDs and corticosteroids
Early diagnosis and aggressive treatment of H
pylori
Careful surgical technique during the primary bypass to minimize tension or ischemia at the anastomosis.
Prognosis
Factors Affecting Prognosis:
The success of surgical resection depends on the extent of disease, presence of complications (like perforation), and the surgeon's experience
Medical management alone can achieve healing in many cases but recurrence is common.
Outcomes:
Surgical resection offers definitive treatment for complex cases, with good long-term outcomes regarding ulcer resolution
However, the risk of recurrence remains, and ongoing medical management is often necessary.
Follow Up:
Lifelong follow-up is recommended for all patients with a history of marginal ulcers
Regular endoscopic surveillance, especially in patients with risk factors, is crucial to detect early recurrence or complications.
Key Points
Exam Focus:
Marginal ulcers are a key complication of RYGB
Understand the incidence, risk factors, and diagnostic modalities (EGD is gold standard)
Medical management with PPIs and H
pylori eradication is first-line
Surgical revision is for refractory or complicated cases.
Clinical Pearls:
Always consider marginal ulcer in a gastric bypass patient presenting with new or worsening epigastric pain
Biopsy suspected ulcers to rule out malignancy
Aggressive PPI therapy is vital for healing
Consider anastomotic technique and tension during primary bypass to prevent recurrence.
Common Mistakes:
Underestimating the severity of symptoms
Delaying endoscopy
Inadequate PPI dosing or duration
Failing to test for and eradicate H
pylori
Not considering surgical revision for refractory cases or severe complications like perforation.