What are marginal ulcers (peptic ulcers occurring at the margin of a gastrojejunal anastomosis)?

From the Guidelines

Marginal ulcers are a common complication after gastric bypass surgery, occurring in 0.6-16% of patients, and are characterized by open sores that develop at the anastomotic site where the small intestine connects to the stomach. These ulcers typically form on the intestinal side of the connection and can lead to bleeding and perforation, requiring urgent treatment 1. The primary causes of marginal ulcers include excessive acid production, Helicobacter pylori infection, use of NSAIDs or other ulcerogenic medications, smoking, and alcohol consumption.

Key Characteristics of Marginal Ulcers

• They can be classified into early and late ulcers, depending on the timing of the diagnosis, with early ulcers more likely to be associated with local factors such as ischemia, postoperative inflammation, stenosis, and the presence of a foreign body 1.
• Late marginal ulcers are likely related to increased acid exposure of the gastro-jejunal anastomosis developing over time 1.
• Patients often experience abdominal pain, nausea, vomiting, and occasionally bleeding or perforation in severe cases.

Treatment and Management

• Treatment typically involves proton pump inhibitors (PPIs) such as omeprazole 40mg daily or pantoprazole 40mg daily for 3-6 months, as well as elimination of potential risk factors and regular endoscopic control to monitor healing and rule out stenosis 1.
• The use of PPIs prophylactically in the perioperative phase, particularly for longer durations such as 3 months, has been shown to significantly reduce the incidence of marginal ulcers 1.
• H. pylori testing and eradication therapy with clarithromycin, amoxicillin, and a PPI for 14 days is recommended if infection is present.
• Patients should discontinue NSAIDs, quit smoking, and avoid alcohol to prevent recurrence.
• Surgical intervention may be necessary for ulcers that don't respond to medical management or those with complications like perforation or severe bleeding.

From the Research

Definition and Prevalence of Marginal Ulcers

• Marginal ulcers are a potential complication following Roux-en-Y gastric bypass (RYGB), with a mean prevalence of 4.6% 2
• They can occur at the gastrojejunal anastomosis and are a common cause of morbidity after gastric bypass surgery

Etiology and Risk Factors

• The pathophysiology of marginal ulcers is complex and involves multiple factors, including:
  • Smoking 2, 3
  • Helicobacter pylori infection 2
  • Non-steroidal anti-inflammatory drug (NSAID) use 2
  • Larger pouch size 2, 3
  • Diabetes 3
• These factors can contribute to increased acid exposure and mucosal ischemia, leading to marginal ulcer formation

Symptoms and Complications

• Patients with marginal ulcers may experience:
  • Acute or chronic abdominal pain 2, 3
  • Bleeding 4, 3
  • Perforation 2
  • Strictures 2
• Rarely, marginal ulcers can erode into adjacent structures, such as the main splenic artery, leading to life-threatening hemorrhage 4

Diagnosis and Management

• Diagnosis is typically made by endoscopy 2, 3
• Management involves modification of risk factors and medical therapy focused on proton pump inhibitors 2
• Surgical intervention may be required for complicated ulcers, such as those with bleeding, perforation, or strictures 2, 5
• Options for surgical management include:
  • Revision of the gastrojejunal anastomosis 5
  • Subtotal gastrectomy 5
  • Total gastrectomy with esophagojejunal anastomosis 5
  • Video-assisted thoracoscopic truncal vagotomy 6, 5