What is a marginal ulcer?

Marginal Ulcer: Definition, Pathophysiology, and Management

A marginal ulcer is an ulceration that develops at the gastrojejunal anastomosis after bariatric surgery, particularly Roux-en-Y gastric bypass (RYGB), with an incidence ranging from 0.6% to 16% of patients who undergo this procedure. 1

Definition and Classification

Marginal ulcers are classified into two types based on timing:

• Early marginal ulcers: Occur 1-10 months after surgery, associated with local factors such as:

  • Ischemia
  • Postoperative inflammation
  • Stenosis
  • Presence of foreign bodies (e.g., sutures)

• Late marginal ulcers: Develop later, primarily related to increased acid exposure of the gastrojejunal anastomosis over time 2

Anatomical Location

• Typically located on the jejunal side of the gastrojejunostomy anastomosis
• May be found on the anastomosis itself (50%) or in the jejunum (40%) 3
• Visible sutures are present in approximately 35% of cases 3

Risk Factors

Several factors increase the risk of developing marginal ulcers:

• Smoking: Strong association with 2.5 times increased risk 3
• Diabetes: Significant risk factor (OR 5.6 on multivariate analysis) 3
• Medications: NSAIDs and steroids use
• Longer gastric pouch: Each additional cm increases risk by 20% 3
• Helicobacter pylori infection
• Immunosuppression
• Technical factors: Tension at anastomosis, poor surgical technique 1

Clinical Presentation

Patients with marginal ulcers commonly present with:

• Abdominal pain (63% of cases) - typically mid-epigastric 3, 4
• Upper gastrointestinal bleeding (24% of cases) 3
• Perforation: Occurs in approximately 1% of RYGB patients 1
• Stenosis/stricture formation

Diagnosis

• Endoscopy: Gold standard for diagnosis, allowing direct visualization and biopsy to exclude malignancy 1
• Biopsy: Always recommended to rule out malignancy 2

Management

Medical Management

• Proton pump inhibitors (PPIs): First-line treatment for 3-6 months 2
• Risk factor modification:
  • Smoking cessation
  • Avoidance of NSAIDs and steroids
  • H. pylori eradication if present
• Regular endoscopic monitoring: To assess healing and rule out stenosis 5

Management of Complications

1. Bleeding:

   • Endoscopic evaluation and treatment in hemodynamically stable patients
   • Angiography with transcatheter angioembolization for refractory bleeding
   • Surgical intervention for recurrent bleeding from ulcers >2cm 2

2. Perforation:

   • Laparoscopic primary suture with omental patch for perforations <1cm in stable patients 2
   • Open surgery for unstable patients or complex cases
   • Biopsy of perforated ulcer to exclude malignancy 2

3. Refractory Ulcers:

   • Rule out gastro-gastric fistula or Zollinger-Ellison syndrome
   • Revisional surgery may be necessary (resection and reconstruction of gastrojejunal anastomosis) 2

Prevention

• Prophylactic PPI therapy: Significantly reduces risk of marginal ulcers 4
• Smoking cessation
• Avoidance of NSAIDs and steroids
• Proper surgical technique: Minimize tension and ischemia at anastomosis

Prognosis

• Most marginal ulcers respond well to medical treatment
• Approximately 9% of patients may require surgical revision 3
• After surgical revision, only 36% of patients experience complete symptom resolution, with 57% developing recurrent ulcers 2
• Mortality rate for perforated marginal ulcers can be up to 30% 1

Pitfalls and Caveats

• Delayed diagnosis: Symptoms may be vague or attributed to other causes
• Inadequate treatment duration: PPIs should be continued for at least 3-6 months
• Failure to identify risk factors: Particularly ongoing smoking or NSAID use
• Overlooking gastro-gastric fistula: Present in 8% of marginal ulcer cases 3
• Incomplete evaluation of perforated ulcers: Always obtain biopsies to rule out malignancy