What is the workup and treatment for marginal ulcers in bariatric patients?

Workup and Treatment of Marginal Ulcers in Bariatric Patients

For bariatric patients with marginal ulcers, the diagnostic workup should begin with endoscopy, followed by treatment with high-dose proton pump inhibitors (preferably opened capsules), risk factor modification, and surgical intervention for complications or refractory cases.

Diagnostic Workup

Initial Assessment

• Recognize common presenting symptoms:
  • Abdominal pain (most common symptom, occurring in 99.5% of cases) 1
  • Gastrointestinal bleeding
  • Dysphagia
  • Early satiety
  • Nausea/vomiting

Diagnostic Studies

1. Endoscopy: Gold standard for diagnosis 2

   • Should be performed by an expert endoscopist familiar with post-bariatric anatomy 2
   • Allows direct visualization of the ulcer and biopsy to exclude malignancy
   • Mandatory biopsy of all ulcers to rule out malignancy 2, 3

2. CT scan with contrast:

   • Most commonly used imaging modality (used in 72% of cases) 1
   • Particularly valuable for detecting complications like perforation
   • May show wall thickening, focal outpouching, or mucosal interruption 3

Classification and Risk Factors

Classification

• Early marginal ulcers: Occur 1-10 months post-surgery

  • Usually associated with local factors (ischemia, inflammation, stenosis, foreign body) 2

• Late marginal ulcers: Occur beyond 10 months post-surgery

  • Often related to increased acid exposure at gastrojejunal anastomosis 2
  • Can occur 12-84 months after surgery 4

Risk Factors to Identify

• Smoking (significant risk factor, present in 41% of perforation cases) 1
• NSAID use (present in 23% of perforation cases) 1
• Inadequate PPI prophylaxis (only 15% of patients with perforations were on PPIs) 1
• H. pylori infection 5
• Larger gastric pouch size 5
• Immunosuppression 2

Treatment Algorithm

1. Medical Management (First-Line)

• Proton Pump Inhibitors (PPIs):

  • Opened capsule PPIs are superior to intact capsules for marginal ulcers after RYGB
    • Median healing time: 91 days for opened capsules vs. 342 days for intact capsules 6
    • Fewer endoscopic procedures required 6
  • Continue for minimum 3-6 months 2
  • Consider maintenance therapy for high-risk patients

• Risk Factor Modification:

  • Smoking cessation
  • Discontinue NSAIDs
  • Test and treat for H. pylori if positive

2. Endoscopic Monitoring

• Regular endoscopic control to monitor healing and rule out stenosis 2
• Multiple follow-up endoscopies recommended until complete healing is confirmed 4
• Average healing time with PPIs: approximately 7 months 4

3. Management of Complications

Bleeding Marginal Ulcer

1. Hemodynamically stable patients:

   • Early endoscopic evaluation and treatment 2
   • Hemostasis techniques: injection of epinephrine, mechanical hemostasis with clips, or rubber band ligation (preferred over thermal methods) 2
   • Hemostatic powders may be considered in selected cases 2

2. Refractory bleeding:

   • Angiography with transcatheter angioembolization if endoscopic hemostasis fails 2
   • Surgical intervention for recurrent bleeding from ulcers >2cm 2

Perforated Marginal Ulcer

• Occurs in approximately 1% of RYGB patients 2, 1
• Treatment options:

  1. Laparoscopic approach (preferred in stable patients):

     • Primary suture repair with omental patch for perforations <1cm 2
     • Biopsy of ulceration to exclude malignancy 2

  2. Open surgery (for unstable patients or complex cases):

     • Consider damage control surgery in hemodynamically unstable patients 2

Recurrent/Refractory Ulcers

• Often due to:

  • Gastric pouch enlargement
  • Gastro-gastric fistula
  • Increased acid exposure 2

• Management options:

  • Rule out Zollinger-Ellison syndrome 2
  • Revisional surgery: resection and reconstruction of gastrojejunal anastomosis ± partial remnant gastrectomy 2, 5

Special Considerations

Excluded Gastric Remnant

• Access to excluded segments (gastric remnant, duodenum) is challenging
• Options for assessment:
  • Pediatric colonoscope (reaches remnant in up to 68% of cases) 2
  • Double-balloon technique (success rate 88%, but 10% perforation risk) 2
  • Temporary laparoscopic gastrostomy through remnant for transgastric endoscopy 2

Gastro-gastric Fistula

• Should be suspected with recurrent or perforated marginal ulcers 2
• May require revision bariatric surgery by experienced surgeon 2

Prognosis

• Overall risk for marginal ulcers: approximately 1% per patient-year 7
• Mortality rate for perforated marginal ulcers: 0.97% 1
• Recurrence rate after treatment: 5% 1
• Patients with surgical revision for marginal ulcers:
  • Resolution of symptoms in only 36% of cases
  • Recurrent ulcers in 57% 2

Common Pitfalls to Avoid

• Failing to perform biopsy of gastric ulcers to exclude malignancy 3
• Inadequate PPI dosing or formulation (opened capsules superior to intact) 6
• Insufficient follow-up endoscopies (multiple evaluations needed to confirm healing) 4
• Overlooking risk factors like smoking and NSAID use 1
• Failing to assess for gastro-gastric fistula in recurrent cases 2