Case Report
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Sep 16, 2020; 12(9): 297-303
Published online Sep 16, 2020. doi: 10.4253/wjge.v12.i9.297
Endoscopic approach to gastric remnant outlet obstruction after gastric bypass: A case report
Arash Zarrin, Sufian Sorathia, Vivek Choksi, Steven Robert Kaplan, Franklin Kasmin
Arash Zarrin, Department of Internal Medicine, Aventura Hospital and Medical Center, Miami, FL 33180, United States
Sufian Sorathia, Vivek Choksi, Steven Robert Kaplan, Franklin Kasmin, Department of Gastroenterology, Aventura Hospital and Medical Center, Miami, FL 33180, United States
Author contributions: Zarrin A, Sorathia S and Choksi V reviewed the literature and contributed to manuscript drafting; Zarrin A, Sorathia S and Kasmin F performed the Gastroenterology consultation; Kasmin F performed the endoscopy; Kaplan S and Kasmin F were responsible for the revision of the manuscript for important intellectual content; all authors issued final approval for the version to be submitted.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: No conflicts of interest declared.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Arash Zarrin, DO, Doctor, Department of Internal Medicine, Aventura Hospital and Medical Center, 20900 Biscayne BLVD, Miami, FL 33180, United States. arash.zarrin@hcahealthcare.com
Received: May 12, 2020
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
Abstract
BACKGROUND

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.

CASE SUMMARY

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.

CONCLUSION

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.

Keywords: Gastrointestinal bleeding; Gastric outlet obstruction; Gastric remnant; Endoscopic ultrasound directed transgastric intervention; Gastrogastrostomy; Case report

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.