Ulcerations after Roux-en-Y Gastric Bypass (RYGB) are one of the possible complications causing the patient pain and the bariatric surgeon headaches. The more prevalent case is the Marginal Ulcer (MU), mucosal erosion at the gastrojejunal anastomosis. This condition can be treated with medications; however, surgical intervention is needed in severe cases.

Smoking, caffeinated drinks, alcohol, and certain medications like corticosteroids and NSAIDs are major risk factors for gastric bypass ulcers.

This post explains the types, causation, and medical and surgical management of symptomatic ulcers after RYGB in detail.

What is an Ulcer?

Ulcers are the breakdown of the gastrointestinal tract lining (mucosa), which acts as a protective barrier for gut hormones and digestive juices. Excessive acid production (Pepsin) and medications are common causes of Peptic Ulcer Disease (PUD). Peptic ulcerations can form in the esophagus, stomach, or duodenum. It is usually benign but can become malignant and lead to stomach cancer.

To determine whether or not you have an ulcer, you need an endoscopy to see the status of your stomach coating and if the mucosal erosion is present.

Abdominal pain is the number one symptom in patients with an ulcer. Subjects may also face issues such as bleeding, bloody stools, hematemesis, leakage, and, in severe cases, perforation.

Ulcer Types

What Causes Ulcers After Bariatric Surgery?

Ulcers can arise after weight loss surgery, particularly in gastric bypass, at any time frame (early or late). The frequency of developing ulcers following RNY bypass is typically less than 16%, of which 6.6% are symptomatic, and 1.1% present themselves with perforation.[1] There is a higher incidence of MU in patients with an antecolic RYGB than in patients with a retrocolic RYGB.[2]

People taking aspirin (ibuprofen) on a regular basis are not a good candidate for gastric bypass and need to choose gastric sleeve surgery instead.

The etiology of post-surgical ulceration in bypass patients is elusive and multifactorial. Leading causes of gastric bypass ulceration include acidic or spicy foods, drinking coffee, alcohol, steroids (Prednisone), tobacco use, NSAIDs (Ibuprofen, Motrin, Aleve, and Naproxen), Helicobacter Pylori (H. Pylori), stress, small vessel ischemia, hypertension, diabetes, sleep apnea, and non-absorbable sutures.

Nicotine reduces oxygen supply to the stomach lining tissues and impairs scar healing. Most bariatric programs require you to stop smoking before and after surgery.

NSAIDs – Non-Steroidal Anti-Inflammatories Drugs – can create inflammation (gastritis) or ulcers in the stomach. The damages can develop anytime between the first few months to several years after.

Symptoms and Side Effects of Ulcers

Symptoms of ulcers after gastric bypass

The most common symptoms of stomach ulcers post-gastric bypass surgery are:

  • Upper abdominal pain (especially after meals)
  • Bloating and gas
  • Nausea
  • Vomiting
  • Stomal obstruction
  • Loss of appetite
  • Bleeding (blood in stool/vomit)

Bleeding ulcers can lead to anemia in patients. Other problems you could encounter include Gastrogastric Fistula, a condition where the acid content and blood leak from your pouch to the intestines, prompting severe stomach pain, nausea, and vomiting. About 25% of people with Marginal Ulcer complications are asymptomatic.

Don’t Ignore the Symptoms

Ulcers can quickly become a severe after-effects and a life threatening situation. Ignoring these symptoms can put you at risk for bleeding, stomach perforation, or worse. Ulcers should be diagnosed and treated by your medical physician.

Types of Ulcers After Gastric Bypass

Marginal ulcers/stomal ulcers are more common due to intestinal rerouting, which connects the lower intestines to the stomach to bypass digestion. Most of the time, marginal ulcers are a byproduct of smoking and taking medications like NSAIDs and steroids.

There are two core types of ulcerations that RNY patients are more susceptible to,

1. Duodenum Ulcer

The eroded coating on the duodenum side in the remnant stomach or duodenum is known as a peptic ulcer. This type of ulcer is rare in patients with rny bypass and can be repaired endoscopically.

2. Jejenum Ulcer

marginal ulcer in jejunal side of gastrojejunal anastomosis

Courtesy researchgate.net

A marginal ulcer (anastomotic ulcer or ischemic ulcer) develops when the integrity of the mucus membrane of the gastrojejunal anastomosis erodes. The erosion is usually on the jejunal side of the G-J anastomosis and forms in the first few centimeters after the anastomosis.

Seldom is the ulcer found on the gastric pouch itself, called a stomal ulcer. A fraction of the patients with anastomotic ulcers end up with Gastro-Gastric Fistulae.

Gastro-gastric fistula (GGF) is caused by disruption of the staple line in the gastric remnant. Anastomotic leakage occurs between the gastric pouch and the remnant stomach. The acid produced in the stomach can backflow into the small pouch to damage the lining.

Gastro-Gastric Fistula in RNY Gastric Bypass

Gastric Bypass Ulcer Treatment & Prevention

Your doctor will monitor the ulcers by inserting a scope through the mouth into the pouch and performing an EsophagoGastroDuodenoscopy (EGD). Typically, using medications will remedy the ulcer and make it go away. In case of bleeding and perforated ulcers, an operation is warranted to deal with the problem.

Non-Surgical Treatment

The Management of symptomatic gastric ulcers in RNY patients usually involves medications, such as proton pump inhibitors (PPIs) and cytoprotective agents (sucralfate). The PPI medical therapy blocks the production of stomach acid and helps cure the ulcer. Always consult with your Primary Care Physician regarding PPIs or individualized medication to help neutralize stomach pain, nausea, or vomiting.

Surgical Treatment

Bleeding ulcers can be treated endoscopically with a lower complication rate than laparoscopic surgery. In the case of a perforated ulcer, when lesions are present and stomach contents leak into the body, an operation is required to fix it. When they heal and recur or never heal, chronic ulcers require revisional surgery. Here are definitive surgical solutions,

surgical treatment of ulcers in gastric bypass - marginal ulcer and gastric-gastric fistula

  1. GastroJejunostomy (GJ) Revision – Chronic and perforated anastomotic revision entails a new gastrojejunostomy. Your bariatric surgeon has to cut out that ulcer and alter the connection between the pouch and the small intestine.
  2. Gastro-Gastric Fistula Revision – If complications accompany the fistula, the treatment also requires partial gastrectomy of the remnant stomach.
  3. Gastric Bypass Reversal – Reversing the gastric bypass with/without a gastric sleeve is also a viable option.

Preventing Ulcers After Gastric Bypass Surgery

Stomach ulcers post-bariatric surgery are painful and discouraging. The discomfort and blood loss can reduce energy levels, lessening your weight loss goals. The bariatric surgeon can make the pouch smaller to help create less acid. They can also use absorbable sutures to lessen the chance of ulceration.

Fortunately, there are things you can do to prevent postoperative stomach ulcers:

  • Follow a nutritious diet
  • Avoid foods that trigger stomach pain.
  • Drink plenty of fluids, especially water, to stay hydrated.
  • Avoid alcohol.
  • Avoid smoking and using tobacco products.
  • Manage stress levels.
  • Take medications prescribed by your surgeon to help protect the stomach lining.

Take Away

Bariatrics free patients from obesity and its underlying medical conditions. Some Roux-en-Y bypass patients may experience stomal and anastomosis ulcers after the operation. Overall, the best way to prevent stomach ulcers after gastric bypass surgery is to carefully adhere to your surgeon’s instructions and perform endoscopy often. Be proactive about your health and keep track of any changes in your stomach ulcer symptoms. If you have any concerns, contact your bariatric specialist right away.