Marginal ulcer

Marginal ulcer (also called stomal ulcer or anastomotic ulcer) is a mucosal ulceration that develops at or near a surgical gastroenteric anastomosis, most commonly on the jejunal side of the gastrojejunostomy after Roux-en-Y gastric bypass (RYGB). It is the most common late complication of RYGB and may present to the emergency department with pain, GI bleeding, or perforation.

Background

• Incidence ranges from 0.6% to 25% following RYGB, with a mean prevalence of approximately 4.6%
• Typically presents a median of 1-2 years after surgery, but can occur from weeks to >10 years postoperatively
• Ulcers are located on the anastomosis (~50%) or the jejunal mucosa (~40%)
• Pathophysiology is multifactorial:
  • Acid exposure — jejunal mucosa lacks protective buffering mechanisms against gastric acid
  • Ischemia — tension on the anastomosis, compromised local blood supply
  • Large gastric pouch — greater parietal cell mass increases acid production
  • Foreign body reaction — non-absorbable suture material or exposed staples at the anastomosis
  • Gastrogastric fistula — allows acid from the excluded gastric remnant to reach the pouch
• Risk factors (by meta-analysis):
  • Helicobacter pylori infection (OR 4.97)
  • Smoking (OR 2.50)
  • Diabetes mellitus (OR 1.80)
  • NSAID / aspirin use
  • Corticosteroid use
  • History of peptic ulcer disease
  • Alcohol use
  • SSRI use (proposed mechanism: impaired mucosal healing)

Clinical Features

• Epigastric or periumbilical pain (most common, ~63%)
  • Often postprandial, may mimic pre-bypass peptic ulcer disease
• Nausea and vomiting
• Reduced oral intake / early satiety
• GI bleeding (~24%)
  • Melena, hematemesis, or occult blood loss with iron deficiency anemia
• Dysphagia (if associated anastomotic stricture)
• Complicated presentations:
  • Perforation — acute-onset severe abdominal pain, peritoneal signs, sepsis
    • May present with left shoulder pain (diaphragmatic irritation)
  • Hemorrhage — hemodynamic instability, hematemesis, hematochezia
  • Stricture — progressive dysphagia, vomiting, inability to tolerate oral intake
  • Gastrogastric fistula — chronic symptoms, weight regain
• Up to 28% of patients may be asymptomatic (discovered incidentally on surveillance endoscopy)

Differential Diagnosis

Diffuse Abdominal pain

• Abdominal aortic aneurysm
  • Aortocaval fistula
• Acute gastroenteritis
• Aortoenteric fisulta
• Appendicitis (early)
• Bowel obstruction
  • Large bowel obstruction
    • Ogilvie's syndrome
  • Small bowel obstruction
  • Malignant bowel obstruction
• Bowel perforation
• Diabetic ketoacidosis
• Gastroparesis
• Hernia
• Hypercalcemia
• Inflammatory bowel disease
• Mesenteric ischemia
  • Mesenteric vein thrombosis
• Pancreatitis
• Peritonitis
• Sickle cell crisis
• Spontaneous bacterial peritonitis
• Volvulus
• Peptic ulcer disease
• Anastomotic leak (early postoperative period)
• Anastomotic stricture
• Internal hernia (post-bariatric)
• Small bowel obstruction
• Cholelithiasis / cholecystitis (common after rapid weight loss)
• Pancreatitis
• Mesenteric ischemia
• Gastrogastric fistula
• Gastritis

Evaluation

Workup

• Labs:
  • CBC — anemia (chronic blood loss), leukocytosis (perforation/infection)
  • BMP — electrolyte abnormalities from vomiting or poor oral intake
  • Lipase — rule out pancreatitis
  • Lactate — if concern for perforation or ischemia
  • Type and screen — if GI bleeding
  • H. pylori testing (stool antigen or urea breath test preferred over serology post-bypass)
  • Iron studies — if chronic anemia
• Imaging:
  • CT abdomen/pelvis with IV contrast — study of choice in the ED for suspected complications
    • May show: wall thickening at the gastrojejunostomy, periananastomotic fat stranding, extraluminal air (perforation), extraluminal fluid, oral contrast leak
    • CT also evaluates for internal hernia, small bowel obstruction, and abscess
  • Upright CXR or left lateral decubitus — may show free air under diaphragm if perforation
  • UGI fluoroscopy with water-soluble contrast — can confirm contained perforation vs free leak
• EGD (esophagogastroduodenoscopy):
  • Gold standard for diagnosis
  • Directly visualizes ulcer at or near gastrojejunostomy
  • Evaluates for exposed suture/staple material, gastrogastric fistula, stricture
  • Allows biopsy (rule out malignancy, test for H. pylori)
  • Enables therapeutic intervention (hemostasis, dilation)
  • May not be immediately available in the ED setting

Diagnosis

• Suspect in any post-bariatric surgery patient presenting with epigastric pain, GI bleeding, or signs of perforation
• Definitive diagnosis by EGD with direct visualization of ulcer at the gastrojejunal anastomosis
• CT findings suggestive but not diagnostic; primarily used to identify complications (perforation, abscess, obstruction)
• Visible suture material or staples at the ulcer base is a characteristic finding

Management

Medical management (uncomplicated)

• Proton pump inhibitor (PPI) — mainstay of treatment
  • High-dose PPI (e.g., omeprazole 40 mg BID or pantoprazole 40 mg BID)
  • Duration: minimum 8-12 weeks; many patients require long-term or indefinite PPI
• Sucralfate 1 g QID (mucosal protectant, adjunct to PPI)
• Risk factor modification:
  • Smoking cessation (critical)
  • Discontinue NSAIDs, aspirin (if possible; discuss with prescribing physician)
  • Limit alcohol
  • H. pylori eradication if positive
  • Optimize glycemic control in diabetics
  • Discontinue or minimize corticosteroids
• Endoscopic removal of exposed foreign material (sutures, staples) if identified

GI bleeding

• Standard approach to Upper GI bleed
• Aggressive resuscitation, blood transfusion as needed
• IV PPI (e.g., pantoprazole 80 mg bolus then 8 mg/hr drip)
• Urgent EGD for diagnosis and hemostasis (clips, epinephrine injection, thermal therapy)
• Consult surgery if hemodynamically unstable or endoscopy fails to achieve hemostasis
• See Upper GI bleed

Perforation

• Surgical emergency in most cases
• NPO, IV fluid resuscitation, broad-spectrum antibiotics
• IV PPI
• Surgical options:
  • Omental (Graham) patch repair — most common initial approach
  • Anastomotic revision with resection of ulcer bed
  • Gastric bypass reversal (complex, reserved for refractory cases)
• Laparoscopic approach preferred if patient is hemodynamically stable and presents within 24 hours
• Contained perforation in select hemodynamically stable patients with minimal symptoms may be considered for non-operative management with NPO, IV antibiotics, and IV PPI (emerging evidence)

Stricture

• Endoscopic balloon dilation (may require serial dilations)
• Continue PPI therapy
• Surgical revision if refractory

Disposition

• Admit if:
  • Signs of perforation or peritonitis → emergent surgical consultation
  • Hemodynamically significant GI bleeding
  • Inability to tolerate oral intake
  • Severe pain requiring IV analgesia
  • Concern for sepsis or abscess
• Discharge may be appropriate if:
  • Mild symptoms with stable vital signs
  • Tolerating oral intake
  • Reliable follow-up arranged (PPI prescription, outpatient EGD referral, bariatric surgery follow-up)
  • Clear return precautions given: worsening pain, vomiting, bloody or tarry stools, fever, lightheadedness
• Recurrence rate is high (~30% or more), especially if risk factors are not addressed
• Approximately 9% of patients ultimately require surgical revision despite medical therapy
• Endoscopic surveillance is recommended given high recurrence rate

See Also

• Peptic ulcer disease
• Upper GI bleed
• Bariatric surgery complications
• Gastric bypass
• Small bowel obstruction
• Internal hernia
• Perforated gastric ulcer
• Helicobacter pylori

External Links

• American Society for Metabolic and Bariatric Surgery (ASMBS)