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 4 Flow diagram showing a proposed diagnostic/therapeutic algorithm for patients status post Roux-en-Y gastric bypass surgery presenting with acute gastrointestinal bleeding that is highly likely from an upper gastrointestinal source (e. g., patient presenting with melena). The important difference in this algorithm from a general patient with UGI bleeding (who is not status post RYGB) is the addition of push enteroscopy, single balloon enteroscopy, or possibly double balloon enteroscopy if the EGD was non-diagnostic but the excluded stomach and duodenum (afferent limb) had not been intubated and viewed at EGD. Alternative management algorithms include: (1) performing push enteroscopy or single balloon enteroscopy initially instead of EGD in patients status post RYGB; or (2) performing colonoscopy before performing push enteroscopy or single balloon enteroscopy (or double balloon enteroscopy) after a non-diagnostic EGD. RYGB: Roux-en-Y gastric bypass; EGD: Esophagogastroduodenoscopy.