Published online Sep 16, 2020. doi: 10.4253/wjge.v12.i9.297
Peer-review started: May 8, 2020
First decision: May 26, 2020
Revised: June 4, 2020
Accepted: August 15, 2020
Article in press: August 15, 2020
Published online: September 16, 2020
Processing time: 120 Days and 12.3 Hours
Acute gastric remnant bleeding is a rare complication of bariatric surgery. Furthermore, acute bleeding from the gastric remnant resulting in gastric remnant outlet obstruction has not been described previously. Endoscopic management of gastric remnant bleed has been challenging due to difficulty accessing the excluded stomach. Traditionally, this necessitates surgical intervention. Recently, however, the adoption of endoscopic ultrasound-directed transgastric intervention provides an alternative approach to management.
A 65-year-old male with a prior gastric bypass presented with the sudden onset of progressive abdominal distension, nausea, and melena of two days duration. His imaging illustrated a massively distended stomach. A nasogastric tube did not result in drainage of fluid or decompression of his abdomen. His endoscopy revealed a normal-appearing gastro-jejunal anastomosis and confirmed the distended "fluid"-filled gastric remnant. An endoscopic ultrasound-directed gastrogastrostomy was created to decompress the gastric remnant. Two liters of blood was suctioned before a large adherent clot was visualized in the gastric antrum. The patient underwent emergent angiography with embolization of the gastroduodenal artery. He was discharged with a stable hemoglobin level and resolution of symptoms. Healing superficial gastric ulcers were visualized on a follow-up endoscopy. Gastric biopsies were consistent with Helicobacter pylori infection for which the patient was treated, and successful eradication was achieved.
This patient benefited from a timely diagnosis and effective therapy of an acute gastric remnant obstruction from a bleeding ulcer with endoscopic ultrasound-directed transgastric intervention.
Core Tip: The gastric remnant can be safely and effectively accessed by endoscopic ultrasound-directed transgastric intervention by the formation of a gastrogastrostomy using a lumen apposing metal stent to treat several conditions, including but not limited to bleeding gastric ulcers and gastric outlet obstruction among patients who have previously undergone Roux-en-Y gastric bypass. This method is an effective, safe, and less invasive alternative to surgery.