S2181 an Endoscopic Approach to an Unusual Cause of Gastric Remnant Outlet Obstruction after Roux-en-Y Gastric Bypass

INTRODUCTION: Acute gastric remnant bleeding is a rare complication of bariatric surgery. Furthermore, acute bleeding from the gastric remnant resulting in 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 (EDGI) provides an alternative approach to management. Case Description/Methods: A 65-year-old male with a past medical history significant for Roux-en-Y gastric bypass presented to our hospital with sudden onset progressive abdominal distension, nausea, dry-heaves, lightheadedness, and melena for two days. His abdomen was distended but non-tender. The rectal exam exhibited melena. His hemoglobin was 12, which was near his baseline. The CT scan illustrated a massively distended stomach, which was “fluid-” filled (Figure 1). A nasogastric tube was inserted, which did not result in any \ drainage of fluid. The endoscopy revealed a normal-appearing gastro-jejunal anastomosis without marginal ulceration or recent bleeding in either limb. EUS confirmed the distended “fluid-” filled gastric remnant. Using a Hot lumen apposing metal stent under endoscopic ultrasound (EUS) guidance, a gastrogastrostomy was created. The gastric remnant was decompressed, and two liters of blood was suctioned before a large adherent clot was visualized in the gastric antrum. Endoscopic therapy was not pursued due to the size of the clot and concern of stent dislodgement. He underwent emergent angiography with embolization of the gastroduodenal artery. He was discharged with a stable hemoglobin level and resolution of abdominal distension and bleeding after two days. Healing superficial gastric ulcers were visualized on follow up endoscopy. Gastric biopsies were consistent with Helicobacter pylori infection for which the patient was treated, and successful eradication was achieved. DISCUSSION: Historically, ulceration of the gastric remnant has been treated by laparotomy and endoscopy through either a surgical gastrostomy or by enteroscopy. Our case adds to the recent literature evidence for safe and efficacious access to the excluded stomach by EDGI. It sets a precedent for the use of this technique in treating similar clinical scenarios. This method is an effective, safe, and less invasive alternative to surgery.Figure 1.: CT scan exhibiting gastric remnant outlet obstruction.Figure 2.: Endoscopy.Figure 3.: A large clot in the antrum of the excluded stomach.