Two case reports of acute upper gastrointestinal bleeding from duodenal ulcers after Roux-en-Y gastric bypass surgery: Endoscopic diagnosis and therapy by single balloon or push enteroscopy after missed diagnosis by standard esophagogastroduodenoscopy

Figure 1 Endoscopic findings and therapy during single balloon enteroscopy in Case 1. A: Diagnostic findings. Single balloon enteroscopy performed in a 44-year-old woman, status post Roux-en-Y gastric bypass (RYGB) surgery 11 years earlier for morbid obesity, who presented with acute melena and a hemoglobin decline to 5.8 g/dL demonstrates a 4-cm-wide bulbar ulcer with a non-bleeding visible vessel in the afferent limb. Note the retrograde view of the duodenal bulb with the pylorus seen in the distance. Esophagogastroduodenoscopy performed 3 d earlier for melena had revealed no upper gastrointestinal lesions, but the afferent limb of the Roux-en-Y, including the excluded proximal duodenum and stomach, had not been intubated and visualized because of technical difficulties at esophagogastroduodenoscopy; B: Endoscopic therapy. Single balloon enteroscopy showing the ablated bulbar ulcer after dual therapy of dilute epinephrine injection and heater probe thermocoagulation.