 |
| Photo of Intraoperative Photo by M Clock |
As you may see a recurrent theme in your practice from time to time, we do as well in Bariatric Surgery. We've had a run on perforated Marginal Ulcers lately. Three cases in the last few weeks to be exact.
I remember my days of Primary Care, and seeing what seemed like a cluster of Bell's Palsy, or Shingles, or DVT's - things that you do see from time to time, but over a short interval, interacting with it more frequently than you would ordinarily expect to, given the relative scarcity of it as a common presentation averaged out over the longer haul of regular practice.
Marginal ulcers are not that infrequently seen, but perforated marginal ulcers are certainly less frequently encountered, but the natural end to a smoldering presentation of the former, a logical possible endpoint complicating the run-of-the-mill ulcer or pouch gastritits.
Marginal ulcers are frequently seen in the post Gastric Bypass population, and represent an ulcer of the gastric pouch or more commonly just distal to the gastro-jejunal anastamosis, in the Roux limb (the jejunal limb that connects to the gastric pouch). The most common presentation is ongoing epigastric abdominal pain, similar to what you may expect for how PUD would present.
The most common risk factors are NSAIDs smoking, and occasionally environmental stressors.
Our patients are repetitively advised to avoid all NSAIDs post op, as they can easily induce an ulcer to form, or rapidly encourage one to go on to perforate, resulting in a trip to the OR for an urgent diagnostic laparoscopy and some form of ulcer repair. We either do a primary closure of the ulcer / perforation, and/or likely a Graham Patch of the area to add further reinforcement to the inflamed and edematous area that perforated.
Often times, when we question patients that either have an ulcer or a perforation, they may admit to getting back to their smoking habit, or (sometimes unknowingly) taking NSAIDs, and that usually cinches the diagnosis, and gets us started with a treatment of Carafate and high-dose BID PPIs. An EGD may be performed shortly thereafter, if they clinically do not respond as we would expect within a week or two.
I have had patients tell us that they thought Tylenol was the same as the Alleve they have been taking, because they knew that Aspirin and Advil were off limits. Or patients say that their Orthopedic doctor put them on a 2 week course of a "pain medicine" (an NSAID) even though the patient told them that they had a Gastric Bypass, but they were reassured that it would be OK.
We had a fairly typical recent case of an out-of-towner who had a Bypass at a hospital in Ohio a couple of years earlier and had 8-12 hours of intense epigastric abdominal pain, went to the ER and was found to have free air, and some CT scan findings implicating the G-J region as causative, suspected to be from a perforated MU (Marginal Ulcer).
The picture above is what we saw upon laparoscopy - a classic look at what was expected with a freshly perforated Marginal Ulcer.
The next photo is the start of the primary closure of the ulcer, with stitches placed above and below the ulcer...
 |
| Photo of Intraoperative Photo by M Clock |
 |
| Photo of Intraoperative Photo by M Clock |
The result is a primary closure, and then a reinforced sealing of the previous site of the ulcer surgically. Drains were then placed in the upper abdomen, and copious irrigation was performed as to lessen the chemical and inflammatory peritonitis that rapidly ensued when the perforation occurred.
Oh, and her risk factors? Ongoing Alleve for the past few weeks for a musculoskeletal complaint, and resumption of her smoking that she had quit before she had surgery.
As is often said - "Common things are Common", but it seems that lately, so are somewhat uncommon things, too!
No comments:
Post a Comment