Management of Ulcers

A common late complication after RYGB and other bariatric procedures is MU, defined as ulcers at the margins of the anastomosis between the gastric pouch and the small bowel. The incidence of MU after gastric bypass ranges from as low as 0.6% to as high as 25%. These ulcers cause significant morbidity, including severe pain, nausea, bleeding, dysphagia, and, rarely, perforation, which may result in multiple readmissions. Patients with painful ulcers are particularly difficult to treat because medical therapy is not often effective. The incidence seems to vary widely depending on the surgical technique, and theories about MU etiology are abundant, including acid, fistula, ischemia, bile reflux, foreign body reactions, inflammation, and Helicobacter pylori. The avoidance of tobacco and NSAIDs and the use of prophylactic PPI is a reasonable measure to decrease the risk of ulcer formation. Long-term medical treatment with PPI seems to heal ulcers in most patients, leaving revision surgery for recalcitrant ulcer disease with variable success. Given the increasing numbers of bariatric procedures, multicenter prospective studies are needed to define strategies to prevent and treat this painful condition.