Smoking history is one of the strongest independent predictors of MU developing following RYGB, conferring nearly 5-fold higher risk compared to non-smokers regardless of how heavily they smoke or even whether the patient has quit smoking. The patient’s history may also reveal modifiable risk factors for developing MU. 11 Critically, up to 28% of patients with MU may be asymptomatic, and some patients may present only with painless upper GI bleeding. 10 Stenosis, a complication of untreated marginal ulcers, presents with dysphagia, solid food intolerance, and delayed vomiting of undigested food. 9 MU perforations may present with pain and an acute abdomen. Gastrogastric fistulas, which occur in approximately 1.18% of patients undergoing RYGB, present with weight regain, insulin resistance, and pain. If the MU is accompanied by other complications, additional symptoms may appear in history. 3, 8 About 20% of patients also experience nausea and vomiting. Patients with marginal ulcers most commonly present with epigastric pain (50-60%) and/or bleeding (15-25%) which may manifest as melena or hematemesis. 7 In a prospective study using endoscopy to screen all RYGB patients at one month following surgery, MU was found in 5.6% of patients. Furthermore, because endoscopy is typically performed on symptomatic patients only, some studies miss asymptomatic MU cases. 4-6 This variability is likely due to the retrospective nature of many studies, and the inconsistencies in diagnosing MU – some only include those diagnosed by endoscopy, while others include those with a probably clinical history. 3 The reported incidence of marginal ulcers varies widely, typically in a range between 1% to 16% of all RYGB cases. MU typically form at the gastrojejunal anastomosis in the proximal jejunum. Marginal ulcers (MU) are a relatively common complication that occurs following RYGB. 1, 2 Although effective, MBS is still a major surgery that carries the risk of various complications. The Roux-en-Y gastric bypass (RYGB) remains one of the most effective and durable metabolic and bariatric procedures producing consistently excellent weight loss and metabolic outcomes. Of the currently available management options, it is evident that metabolic and bariatric surgery (MBS) is among the most effective at inducing long-term weight loss and resolution of obesity-related co-morbidities such as type 2 diabetes, obstructive sleep apnea, and non-alcoholic fatty liver disease. Obesity is one of the fastest-growing public health concerns in the United States. A laparoscopic gastric bypass revision was done to divide the gastrogastric fistula and to separate the gastric pouch from the gastric remnant in order to alleviate the inflamed gastric pouch and prevent further ulcer formation. Upon endoscopy, she was noted to have an inflamed gastric pouch and a gastogastric fistula. Here, we present a case of a female patient status post Roux-en-Y gastric bypass surgery who presented with abdominal pain. Once identified, a gastrogastric fistula may be treated surgically with remnant gastrectomy or gastrojejunostomy revision. Barium contrast radiography is particularly useful and is the preferred initial study method for the detection of staple-line dehiscence, which may be small and overlooked during endoscopy. Diagnosis is made through upper gastrointestinal contrast radiography or CT scan and endoscopy. Etiologies include postoperative Roux-en-Y gastric bypass leaks, incomplete gastric division, marginal ulcers, distal obstruction, and erosion of a foreign body. Patients typically present with nausea and vomiting, abdominal pain, intractable marginal ulcer, bleeding, reflux, poor weight loss, and weight regain. Gastrogastric fistula is a rare complication following a roux-en-y gastric bypass procedure wherein there is a communication between the proximal gastric pouch and the distal gastric remnant.
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