Why do bariatric surgery patients develop peptic ulcers?

From the Guidelines

Bariatric patients develop ulcers primarily due to changes in their digestive anatomy and physiology following weight loss surgery, with a significant risk of marginal ulcers after procedures like gastric bypass or sleeve gastrectomy. After these procedures, patients have an increased risk of ulceration at surgical anastomosis sites where tissue healing may be compromised, as reported in a 2022 study published in the World Journal of Emergency Surgery 1. The altered digestive pathway allows bile acids and digestive enzymes to contact areas of the stomach or small intestine not normally exposed to these irritants.

Some key factors that contribute to the development of ulcers in bariatric patients include:

• Local factors such as ischemia, postoperative inflammation, stenosis, and the presence of a foreign body, which are more likely to be associated with early marginal ulcers 1
• Increased acid exposure of the gastro-jejunal anastomosis developing over time, which is more likely to be associated with late marginal ulcers 1
• Smoking and immunosuppression, which significantly increase the risk of developing marginal ulcers requiring surgical revision 1
• Pre-operative non-steroidal anti-inflammatory drugs use, which also increases the risk of marginal ulcers 1

For prevention, patients should take prescribed proton pump inhibitors like omeprazole 20-40mg daily, especially in the first 3-6 months after surgery, as recommended by a 2022 update on guidelines for perioperative care in bariatric surgery published in the World Journal of Emergency Surgery 1. Additionally, patients should avoid NSAIDs, quit smoking, limit alcohol, and maintain proper nutrition with recommended supplements. A systematic review reported an overall incidence rate of marginal ulcers of 4.6% after RYGB, but this rate can be reduced with prophylactic use of PPIs in the perioperative phase 1.

From the Research

Bariatric Patients and Ulcer Development

• Bariatric patients may develop ulcers due to various factors, including the use of nonsteroidal anti-inflammatory drugs (NSAIDs) 2 and changes in gastrointestinal anatomy and physiology after surgery 3, 4.
• The use of NSAIDs after bariatric surgery can increase the risk of ulcer development, and proton pump inhibitors (PPIs) may be recommended to reduce this risk 2, 5, 6.
• However, the absorption of PPIs may be reduced after bariatric surgery, which can affect their effectiveness in preventing ulcers 3.

Risk Factors for Ulcer Development

• Helicobacter pylori infection is a known risk factor for ulcer development, and its presence can affect the effectiveness of PPIs in preventing ulcers 3, 5.
• The type of bariatric surgery performed can also affect the risk of ulcer development, with some procedures carrying a higher risk than others 4.
• Other factors, such as the use of NSAIDs and the presence of other gastrointestinal conditions, can also contribute to the development of ulcers in bariatric patients 2, 5, 6.

Prevention and Treatment of Ulcers

• PPIs are commonly used to prevent and treat ulcers in bariatric patients, and their effectiveness has been demonstrated in several studies 2, 5, 6.
• However, the optimal dose and duration of PPI therapy after bariatric surgery are not well established, and further research is needed to determine the best approach to preventing and treating ulcers in these patients 3.
• Other strategies, such as avoiding NSAID use and managing Helicobacter pylori infection, can also help reduce the risk of ulcer development in bariatric patients 2, 5.