Hemorrhagic gastritis at the excluded stomach after Roux-en-Y gastric bypass

Anemia frequently occurs in patients after Roux-en-Y gastric bypass. The causes are usually related to surgery, anastomotic site lesions, or malabsorption of nutrients caused by altered anatomy and physiology [1]. A 57-year-old man underwent an uncomplicated laparoscopic Roux-en-Y gastric bypass for morbid obesity and experienced melena and anemia 10 years after surgery. His medical history included hypertension and insulin-dependent diabetes mellitus that disappeared after surgery. Laboratory findings revealed a hemoglobin level of 5.9 g/dL and iron deficiency (iron, 47 µg/dL; ferritin 11 ng/mL; iron saturation, 8.6 %). His medications included vitamin B12 and omeprazole (20 mg/day). Endoscopy, colonoscopy, and abdominal computed tomography showed no abnormalities apart from anatomical changes related to surgery.

Double-balloon enteroscopy showed the pylorus and hemorrhagic erosive pangastritis at the excluded stomach ([Fig. 1] and [Fig. 2], [Video 1]). Biopsy specimens were negative for Helicobacter pylori and demonstrated chronic active gastritis, regenerative activity, and foveolar hyperplasia. The omeprazole dosage was increased to 40 mg/day. The patient progressed without melena, and with a continuing increase in the hemoglobin level. After 3 months of treatment, double-balloon enteroscopy revealed atrophic pangastritis, but no bleeding focus. Laboratory tests exhibited a normal iron profile with a hemoglobin level of 15.5 g/dL, iron 155 µg/dL, ferritin 44.7 ng/mL, and iron saturation, 29.5 %.

Fig. 1 Endoscopic view of the pylorus from the duodenum in a 57-year-old man who had undergone an uncomplicated laparoscopic Roux-en-Y gastric bypass for morbid obesity 10 years earlier and who was experiencing melena and anemia.

Fig. 2 Endoscopic image of hemorrhagic erosive gastritis at the excluded stomach 10 years after Roux-en-Y gastric bypass for morbid obesity.

Double-balloon enteroscopy showing hemorrhagic erosive pangastritis at the excluded stomach.

This case shows the importance of double-balloon enteroscopy for examining the excluded stomach in patients with Roux-en-Y gastric bypass. In addition, double-balloon enteroscopy has proven useful for the evaluation and therapy of obscure gastrointestinal bleeding in patients with a surgically altered upper gastrointestinal anatomy [2].

Endoscopy_UCTN_Code_CCL_1AB_2AD_3AC

 

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Competing interests: None

• References

• 1 Obinwanne KM, Fredrickson KA, Mathiason MA et al. Incidence, treatment, and outcomes of iron deficiency after laparoscopic Roux-en-Y gastric bypass: a 10-year analysis. J Am Coll Surg 2014; 218: 246-252
• 2 Safatle-Ribeiro AV, Kuga R, Iriya K et al. What to expect in the excluded stomach mucosa after vertical banded Roux-en-Y gastric bypass for morbid obesity. J Gastrointest Surg 2007; 11: 133-137