What is the appropriate assessment and management plan for an adult post‑gastric bypass patient with a bleeding marginal ulcer at the gastro‑jejunal anastomosis presenting with melena, light‑headedness, normotension, and a hemoglobin decrease from 12 g/dL to 9.7 g/dL?

Assessment and Management of Bleeding Marginal Ulcer Post-Gastric Bypass

This hemodynamically stable patient with a bleeding marginal ulcer requires urgent upper endoscopy for both diagnosis and therapeutic hemostasis, followed by high-dose PPI therapy for 3-6 months, immediate cessation of all NSAIDs/steroids/smoking, and mandatory ulcer biopsy to exclude malignancy. 1, 2

Immediate Assessment

Hemodynamic Status and Resuscitation

• Patient is currently normotensive but has significant anemia (Hgb 9.7 from baseline 12, representing a 2.3 g/dL drop) with melena and orthostatic symptoms, indicating ongoing or recent significant bleeding 1
• Establish large-bore IV access (two 18-gauge or larger) and initiate crystalloid resuscitation 1
• Type and crossmatch for 2-4 units packed red blood cells; transfuse if Hgb drops below 7-8 g/dL or if hemodynamic instability develops 1
• Serial hemoglobin checks every 4-6 hours to monitor for ongoing bleeding 3
• NPO status immediately 1

Risk Stratification

• This patient remains hemodynamically stable, making them a candidate for endoscopic management rather than immediate surgery 1, 2
• Elicit history of NSAID use, smoking, steroid use, and immunosuppression—all major modifiable risk factors for marginal ulcers 1, 2, 4
• Document time since gastric bypass surgery to classify as early (1-10 months, likely ischemic/inflammatory) versus late (>10 months, likely acid-related) marginal ulcer 1

Diagnostic Plan

Urgent Upper Endoscopy (Within 12-24 Hours)

• Upper endoscopy is the first-line diagnostic and therapeutic intervention for hemodynamically stable patients with bleeding marginal ulcers, as it achieves hemostasis and reduces rebleeding, need for surgery, and mortality 1, 2
• Mandatory biopsy of the ulcer must be obtained to exclude malignancy—this is a strong recommendation that should never be omitted 1, 2, 4
• Use standard endoscopic hemostasis techniques: injection therapy (epinephrine) and mechanical methods (clips, endoscopic suturing) are preferred over thermal techniques to minimize ischemia risk at the anastomosis 2, 5
• Assess for gastro-gastric fistula during endoscopy, as 75% of patients requiring surgical intervention have associated fistulae 1, 4

Alternative Diagnostic/Therapeutic Options if Endoscopy Fails

• Angiography with transcatheter angioembolization should be considered if endoscopic hemostasis fails or is unavailable 1, 2, 6
• Surgical intervention becomes mandatory if bleeding is refractory to endoscopic and angiographic management 1

Therapeutic Management Plan

Immediate Medical Therapy

• Initiate high-dose PPI therapy immediately (e.g., pantoprazole 40 mg IV twice daily, then transition to oral 40 mg twice daily) for a minimum of 3-6 months 1, 2
• Complete smoking cessation is mandatory—smoking is a major modifiable risk factor 1, 2, 4
• Discontinue all NSAIDs and steroids immediately 1, 2, 4
• Address any immunosuppression if present 1, 2

Endoscopic Intervention Strategy

• For actively bleeding ulcers: combination therapy with epinephrine injection plus mechanical closure (clips or endoscopic suturing) provides superior hemostasis 2, 5
• Endoscopic suturing has been successfully used for massively bleeding marginal ulcers and should be considered before proceeding to surgery 5

Surgical Indications

Surgery is indicated if: 1, 2

• Hemodynamic instability develops despite resuscitation
• Refractory bleeding after failed endoscopic and angiographic attempts
• Recurrent bleeding from ulcer >2 cm
• Perforation occurs (requires laparoscopic primary suture with omental patch for perforations <1 cm in stable patients) 1

Follow-Up and Monitoring

Short-Term Monitoring (Inpatient)

• Serial hemoglobin checks every 4-6 hours until stable for 24 hours 3
• Monitor for signs of rebleeding: hematemesis, worsening melena, hemodynamic instability, dropping hemoglobin 1
• Advance diet slowly after endoscopic hemostasis is achieved (clear liquids → full liquids → soft diet) 7

Long-Term Surveillance

• Endoscopic surveillance every 3 months until complete ulcer healing is documented and to rule out stenosis development 2, 3
• Continue high-dose PPI for minimum 3-6 months with regular endoscopic monitoring 1, 2
• If ulcers persist despite 3-6 months of optimal medical therapy, rule out Zollinger-Ellison syndrome and evaluate for structural problems (gastro-gastric fistula, pouch enlargement) 1, 2

Critical Pitfalls to Avoid

• Do not delay endoscopy in hemodynamically stable patients—early endoscopy reduces mortality and need for surgery 1, 2
• Never omit ulcer biopsy—malignancy must be excluded in all cases 1, 2, 4
• Do not use thermal hemostasis techniques preferentially—they increase ischemia risk at the anastomosis; use injection and mechanical methods instead 2
• Always assess for gastro-gastric fistula, as it is present in 75% of cases requiring surgery and causes recurrent ulceration 1, 4
• Do not proceed directly to surgery in stable patients—endoscopic management is successful in the majority of cases 1, 5, 7, 8
• Recognize that only 36% of patients achieve symptom resolution after surgical revision, and 57% develop recurrent ulcers—exhaust medical options first 1, 2

Prognosis and Expectations

• With appropriate PPI therapy, 100% resolution of marginal ulcers can be achieved within 8 weeks in uncomplicated cases 7
• However, 20-24% of patients with marginal ulcers ultimately require surgical intervention for perforation, refractory bleeding, or chronic refractory ulceration 8
• Recurrence rate after surgical revision is high (57%), emphasizing the importance of addressing all modifiable risk factors 1, 2