Belly Pain After Bypass: Marginal Ulcer

Photo from Medscape.com

I saw a patient in the office just the other day with pretty severe abdominal pain, and I thought this might be a good place to  make mention of its cause, incidence, symptoms, treatment and prognosis.

Marginal Ulcer is fairly common after Gastric Bypass, and actually has been around for a long time, described in the literature as an occasional complication of GI surgery in general.  It's incidence is reported as 6-16% of bypass patients, and can occur as early as a few months after surgery to years later.

Patients often present with varying degrees of epigastric abdominal pain, from nuisance-quality to occasionally very severe in nature. It can be associated with some dysphagia, nausea, and anorexia, as well as vomiting and even hematemesis.  Should the pain and/or the symptoms worsen, keep in mind that perforation can occur, and will present as a perforated viscus does.

The history, other than the specifics of the character of the presenting pain, often will further direct the diagnosis.  Smoking and NSAID use, (despite repetitive pre op counsel against the same) are very often the causative factors.  In those without that history, environmental stressors, or even malnutrition may also predispose, but less likely.

Diagnosis is made definitively by Endoscopy (above), but empiric Rx with a notable improvement over 5 -7 days on appropriate treatment can also support the diagnosis, and make EGD unnecessary.

Appropriate treatment consists of a PPI such as Nexium at a higher dose of 40 mg BID, along with Carafate 1g 4 x per day as a slurry or in liquid form.  The Carafate slurry can be created by dissolving a 1g pill in a couple of oz of warmish water and drinking it down.  Swallowing the pill whole will likely pass through the gastric pouch too quickly and diminish its effectiveness. Analgesics such as Lortab may be required for the short term until meds start to take effect.

Paramount to the treatment plan is the strict abstinence from smoking and all NSAID use. Other gastric irritants such as ETOH and caffeine and acidic foods should also be minimized especially if they cause symptoms upon ingestion.

We have seen the occasional patient who continues their smoking or NSAID use, and they commonly recur after they have healed up, or may continue to exhibit moderate to severe symptoms despite maximal medical therapy.

At Endoscopy, if a patient has had prolonged symptoms and has a craterous ulcer that is not healing, we may be able to fibrin glue the defect to encourage healing, but results with this approach have been mixed at best.

Operative treatment may eventually be needed on the rare occasion if the ulcer perforates, or if chronic pain and ulcer are associated with resultant malnutrition.  The approach to that issue can come down to a reversal of the Gastric Bypass - a difficult procedure, but a possibility if it's the only reasonable option left.

The bottom line is, for us and for you in Primary Care is this: Catch an ulcer early, treat it appropriately, and support the patient getting off NSAIDS by offering alternatives, as well as strongly supporting nicotene abstinence by counseling and perhaps a Chantix Rx.  Patients that continue to smoke are at a much greater risk for recurrence and perforation than those who do not.