What are the symptoms and treatment options for a marginal ulcer?

Symptoms of Marginal Ulcer

Marginal ulcers typically present with acute or chronic abdominal pain during meals, accompanied by acid reflux and nausea, and the diagnosis is confirmed via gastroscopy. 1, 2

Clinical Presentation

Primary Symptoms

• Abdominal pain is the hallmark symptom, which can be either acute or chronic in nature 2
• Pain during meals is characteristic, distinguishing marginal ulcers from other post-surgical complications 1
• Acid reflux commonly accompanies the pain 1
• Nausea is frequently reported 1

Complicated Presentations

When marginal ulcers develop complications, the presentation changes significantly:

• Bleeding ulcers: Patients present with signs of gastrointestinal hemorrhage, though notably they typically do not present with septic shock 3
• Perforated ulcers: Patients may experience diffuse chest and abdominal pain that can radiate (e.g., from left shoulder to right lower quadrant), with visible distress, restlessness, and moderate abdominal distention 4
• Stricture formation: Dysphagia may develop alongside the typical ulcer symptoms 1

Diagnostic Confirmation

Gastroscopy (upper endoscopy) is the definitive diagnostic method 1, 2

Critical Diagnostic Steps

• Mandatory biopsy of all ulcers must be obtained to exclude malignancy 5
• The ulcer is typically located on the jejunal side of the gastrojejunostomy anastomosis 3, 2
• Median ulcer size is approximately 10 mm when perforated 3
• Always assess for gastro-gastric fistula, as 75% of patients requiring surgical intervention have associated fistulae 5, 6

Differential Diagnosis Considerations

Marginal ulcers must be distinguished from other post-surgical complications that can present similarly:

• Stenosis or anastomotic complications: Similar pain with dysphagia, confirmed by gastroscopy or contrast swallow studies 1
• Internal herniation: Presents with colicky pain, early fullness, possible ileus/vomiting, but lacks vegetative symptoms that may accompany dumping syndrome 1
• Dumping syndrome: Characterized by cramp-like contractions, bloating, diarrhea, nausea, dizziness, and palpitations occurring after meals 1

Common Pitfalls to Avoid

• Do not assume all post-procedural abdominal pain is benign - maintain high suspicion for marginal ulcers, especially in patients with prior gastric bypass surgery 4
• Do not delay endoscopic evaluation when symptoms suggest marginal ulcer, as complications like bleeding or perforation can develop 5, 2
• Do not forget to obtain biopsies during endoscopy, as malignancy exclusion is mandatory 5
• Recent surgical history can obscure diagnosis - pain beginning immediately after unrelated abdominal surgery (e.g., cholecystectomy) may still represent marginal ulcer perforation 4

Risk Factors to Elicit in History

• NSAID use is a major modifiable risk factor 5, 2
• Smoking significantly increases risk 5, 2
• Steroid use contributes to ulcer development 5
• Helicobacter pylori infection should be assessed 2
• Larger gastric pouch size from original surgery increases risk 2