Marginal ulcer

Background

  • 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).[1]
  • It is the most common late complication of RYGB and may present to the emergency department with pain, GI bleeding, or perforation.


  • Incidence ranges from 0.6% to 25% following RYGB, with a mean prevalence of approximately 4.6%[2]
  • 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[3]
    • 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):[4]

Clinical Features

  • Epigastric or periumbilical pain (most common, ~63%)[5]
  • Nausea and vomiting
  • Reduced oral intake / early satiety
  • GI bleeding (~24%)
  • 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

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[6]
      • 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[7]
    • 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[8]
    • 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:[9]
    • 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)[10]

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[11]
  • Approximately 9% of patients ultimately require surgical revision despite medical therapy
  • Endoscopic surveillance is recommended given high recurrence rate

See Also

External Links

References

  1. ↑ Coblijn UK, Goucham AB, Lagarde SM, Kuiken SD, van Wagensveld BA.
    • Development of ulcer disease after Roux-en-Y gastric bypass, incidence, risk factors, and patient presentation: a systematic review. Obes Surg. 2014;24(2):299-309.
  2. ↑ Azagury DE, Abu Dayyeh BK, Greenwalt IT, Thompson CC. Marginal ulceration after Roux-en-Y gastric bypass surgery: characteristics, risk factors, treatment, and outcomes. Endoscopy. 2011;43(11):950-954.
  3. ↑ Edholm D, Ottosson J, Sundbom M. Importance of pouch size in laparoscopic Roux-en-Y gastric bypass: a cohort study of 14,168 patients. Surg Endosc. 2016;30(5):2011-2015.
  4. ↑ Liang Y, Wang C, Yang L, et al. Nonsurgical risk factors for marginal ulcer following Roux-en-Y gastric bypass for obesity: a systematic review and meta-analysis of 14 cohort studies. Int J Surg. 2024;110(3):1793-1799.
  5. ↑ Azagury DE, Abu Dayyeh BK, Greenwalt IT, Thompson CC. Marginal ulceration after Roux-en-Y gastric bypass surgery: characteristics, risk factors, treatment, and outcomes. Endoscopy. 2011;43(11):950-954.
  6. ↑ Meissnitzer MW, Stättner S, Gmeiner D, et al. Imaging features of marginal ulcers on multidetector CT. Clin Radiol. 2023;78(2):e178-e185.
  7. ↑ Pyke O, Yang J, Cohn T, et al. Marginal ulcer continues to be a major source of morbidity over time following gastric bypass. Surg Endosc. 2019;33(10):3451-3456.
  8. ↑ Schulman AR, Abougergi MS, Thompson CC. H. pylori as a predictor of marginal ulceration: a nationwide analysis. Obesity (Silver Spring). 2017;25(3):522-526.
  9. ↑ Wendling MR, Linn JG, Keplinger KM, et al. Omental patch repair effectively treats perforated marginal ulcer following Roux-en-Y gastric bypass. Surg Endosc. 2013;27(2):384-389.
  10. ↑ Pope R, English W, Walden RL, et al. Non-operative approach to contained perforated marginal ulcers: a systematic review and case series. Am Surg. 2024;90(3):471-477.
  11. ↑ Coblijn UK, Lagarde SM, de Castro SM, Kuiken SD, van Wagensveld BA. Symptomatic marginal ulcer disease after Roux-en-Y gastric bypass: incidence, risk factors and management. Obes Surg. 2015;25(5):805-811.
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