Background

Marginal ulcers can be a complication after Roux-en-Y gastric bypass (RYGB) surgery and are more common in patients that are noncompliant with NSAIDs and smoking. A 37-year-old female presented with sudden onset large volume hematemesis. She underwent a RYGB thirteen years previously at a facility in another state and undergone a c-section three months prior to arriving at our facility. She denied any NSAID, alcohol, or tobacco use. She underwent upper endoscopy and a bleeding visible was noted and epinephrine was injected around the ulcer. This was not sufficient to control the bleeding and she underwent surgical repair with ligation of the left gastric artery (LGA) and revision of the gastrojejunal anastomosis. The LGA is the main blood supply to the gastric pouch after RYGB. She required a take back for final closure and upon inspection no ischemic changes were noted to the gastric pouch. She required TPN for a short period of time before she was able to tolerate oral nutrition. She was also noted to have pleural effusions and required bilateral chest tube for drainage. Once she was tolerating adequate oral intake, she was able to be discharged home. This is an abnormal presentation of a marginal ulcer and was done over a decade after her initial surgery without any of the well-known causes of marginal ulcers. Although the LGA is the main supply of the gastric pouch this demonstrates that there are other blood supply sources to the pouch and can maintain viability of the gastric pouch.