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 2 Endoscopic findings and therapy during push enteroscopy in Case 2. A: Diagnostic findings. Push enteroscopy performed in a 64-year-old woman status post RYGB surgery 10 years earlier for morbid obesity who presented with acute melena and a hemoglobin of 5.1 g/dL demonstrates a 5-mm-wide bulbar ulcer, which is actively oozing blood. EGD performed 5 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 EGD; B: Endoscopic therapy. Push enteroscopy showing the bulbar ulcer after endoscopic treatment with dilute epinephrine, argon plasma coagulation, and hemoclips. RYGB: Roux-en-Y gastric bypass; EGD: Esophagogastroduodenoscopy.