Mr. MM's sister had roux en y gastric bypass a couple years back. She's been having burning "acid" pain and discomfort and took her concerns to her Bariatric Surgeon. He says it's a "Marginal Ulcer." The doctor said there will be NO denying when it perforates, and to get to the hospital. She's pleasantly comforted by that, you bet:
Stomal and Marginal Ulceration
Ulceration occurs in as many as 20% of RYGB patients, usually within 3 months of surgery.[61,62] The ulcers are usually on the efferent side of the gastrojejunostomy, the marginal ulcer.( What causes these ulcers is much debatable. Increased rate of ulceration has been reported after undivided gastric bypass. Local ischemia because of the surgical technique and tension on the pouch may also predispose the RYGB patient to ulceration. In 1976, Mason et al. reported that a larger gastric pouch led to an increased incidence of ulceration, possibly because the larger pouch left more parietal cells capable of producing more acid. The modern RYGB, however, leaves a tiny pouch (about 10-20 mL), which may not contain parietal cells and hence would not produce acid. Two recent studies challenge this theory. In one study, parietal cells were found in the gastric pouch after RYGB in all patients tested. Another study demonstrated lower pH in the gastric pouch in patients with stomal ulcers compared with asymptomatic patients after RYGB. It would therefore seem logical that acid plays a role in some ulcers after RYGB, particularly in patients with a larger gastric pouch.
Patients with stomal or marginal ulceration may present with abdominal pain, nausea, vomiting, or gastrointestinal tract bleeding. Ulceration may also lead to stenosis, resulting in symptoms similar to dysphagia or excessive weight loss.
In most cases, diagnosis can be made with an upper endoscopy. Biopsy specimens should be taken for Helicobacter pylori, which should be treated when present. The role of Helicobacter pylori in stomal and marginal ulceration, however, has not been determined. Although candidates for bariatric surgery are commonly tested for a treated ulceration before surgery, this is not a routine or standard practice. Patients with uncomplicated ulceration may be treated effectively with a proton pump inhibitor, which again suggests that acid influences the pathogenesis of these ulcers. In many instances, however, surgical technique varies and the gastric pouch is larger than it should be. Patients with refractory nonhealing ulcers may require surgical revision. Surreptitious ingestion of nonsteroidal anti-inflammatory drugs must always be considered and investigated.