Perforated pyloric ulcer 13 years after Roux-en-Y gastric bypass: A case report

INTRODUCTION AND IMPORTANCE: Bariatric or metabolic surgery is an emerging surgical specialty. With the increase of obesity and affiliated complications, the Roux-en-Y gastric bypass became a well-established procedure worldwide. CASE PRESENTATION: We present the case of a 46-year-old female patient who presented herself in the emergency department with diffuse abdominal pain, 13 years after a laparoscopic Roux-en-Y gastric bypass. The CT scan found suspicions of an internal hernia. The diagnostic laparoscopy showed a perforated pyloric ulcer of the gastric remnant as well as an internal hernia without any signs of incarceration. The ulcer was repaired by laparoscopic suture and the mesenteric defect at the enteroenterostomy was closed. The testing for H. pylori by different means showed a negative (stool) and a positive (serology) result. CLINICAL DISCUSSION: The loss of connection of the gastric remnant to the oesophagus poses challenges in the diagnostic process: in regard to the perforated ulcer, free air, the most common sign, is absent, and testing of H. pylori presents limited options. CONCLUSION: Bariatric patients remain patients with special considerations even long after undergoing these surgeries because of the drastic change in their anatomy and metabolism. Furthermore, due to the aforementioned reasons, diagnostic by clinical findings and imaging can be difficult and these patients should undergo a diagnostic laparoscopy and multimodal testing for H. pylori.