Single-session endoscopic ultrasound-directed transgastric endoscopy for treatment of upper gastrointestinal bleeding after Roux-en-Y gastric bypass

Endoscopic ultrasound (EUS)-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP) – also known as EDGE – for the purpose of accessing the duodenum to perform EUS or ERCP has been well described in patients who have undergone Roux-en-Y gastric bypass (RYGB) [1]. Few reports, however, have described the use of EDGE to manage upper gastrointestinal bleeding in patients with RYGB anatomy [2].

A 48-year-old woman (Jehovah’s Witness) with a history of RYGB presented with melena and a hemoglobin level of 9.0 g/dL. An upper endoscopy revealed a healthy appearing gastrojejunal anastomosis and no source of bleeding. The hemoglobin level dropped further to 5.0 g/dL and the patient had persistent melena. A computed tomography angiography was concerning for hemorrhagic fluid in the descending duodenum ([Fig. 1]). After discussing possible treatment options with the patient, including balloon-assisted enteroscopy vs. single-session EDGE, the patient opted for the latter.

Fig. 1 Computed tomography demonstrating high-density fluid in the descending duodenum, suggestive of hemorrhagic fluid.

After successful placement ([Fig. 2]) and suturing of a gastrogastric 20 × 10 mm lumen-apposing metal stent (LAMS), the excluded stomach was entered ([Video 1]). An ulcer with a pigmented spot was found in the first portion of the duodenum ([Fig. 3]), which was treated using bipolar cautery. Given the patient’s religious preference to avoid blood products, we then placed a 20 × 10 mm LAMS to tamponade the ulcer and allow healing ([Fig. 4]). Both LAMS were removed 1 month later with complete ulcer healing ([Fig. 5]).

Fig. 2 Balloon dilation of a gastrogastrostomy lumen-apposing metal stent.

Fig. 3 Pigmented spot within a large duodenal ulcer.

Fig. 4 Placement of a 20-mm lumen-apposing metal stent to tamponade the duodenal ulcer.

Fig. 5 Resolution of the duodenal ulcer 1 month after index treatment.

Demonstration of endoscopic ultrasound-directed transgastric endoscopy for the treatment of upper gastrointestinal bleeding in a patient with Roux-en-Y gastric bypass.Video 1

The EDGE procedure allows access to the excluded stomach and duodenum in patients with RYGB anatomy [1]. We describe the use of single-session EDGE to treat gastrointestinal bleeding secondary to peptic ulcer disease. We also highlight how a luminal LAMS was utilized to create a tamponade effect, reducing the exposure to acidic and pancreaticobiliary contents and thus the risk of rebleeding, which was particularly important in this case, given the patient’s religious beliefs.

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Conflict of Interest

S. Han is a consultant for Boston Scientific. J. Burlen, A. Manudhane, L. Roberts, A. Cecilia Amaral, and G. Papachristou declare that they have no conflict of interest.

Acknowledgement

S. Han is supported by the Path to K award from the Ohio State University College of Medicine Office of Research and the Center for Clinical and Translational Science through the Richard P. & Marie R. Bremer Medical Research Fund and William H. Davis Endowment for Basic Medical Research.

• References

• 1 Runge TM, Chiang AL, Kowalski TE. et al. Endoscopic ultrasound-directed transgastric ERCP (EDGE): a retrospective multicenter study. Endoscopy 2021; 53: 611-618
• 2 Marya NB, Sawas T, Chandrasekhara V. et al. Every trick in the book: EUS angiotherapy for management of refractory bleeding secondary to a complicated duodenal ulcer in a patient with Roux-en-Y gastric bypass. VideoGIE 2020; 5: 461-463

Publication History

Article published online:
21 November 2023