AJR 2003; 181:1365-1367
© American Roentgen Ray Society
Using Radiography to Reveal Chronic Jejunal Ischemia as a Complication of Gastric Bypass Surgery
Ross Silver1,
Marc S. Levine1,
Noel N. Williams2 and
Stephen E. Rubesin1
1 Department of Radiology, Hospital of the University of Pennsylvania, 3400
Spruce St., Philadelphia, PA 19104.
2 Department of Surgery, Hospital of the University of Pennsylvania,
Philadelphia, PA 19104.
Received January 27, 2003;
accepted after revision March 6, 2003.
Address correspondence to M. S. Levine
(levine{at}oasis.rad.upenn.edu).
Introduction
Bariatric surgery is being recognized by more and more authorities as the
most effective form of treatment for patients with morbid obesity
[1]. Although a variety of
procedures are available, gastric bypass surgery (usually Roux-en-Y gastric
bypass) accounts for more than 90% of all bariatric surgery currently
performed in the United States
[1]. This procedure involves
construction of a small gastric pouch that is isolated from the distal stomach
and anastomosed to a Roux-en-Y limb of proximal jejunum. Weight loss after
this operation results not only from gastric restriction but also from
malabsorption because of the bypass procedure
[1]. Early complications of
gastric bypass surgery include anastomotic leaks (often leading to abscess
formation or peritonitis), acute distention of the gastric pouch, splenic
injury, and wound infections, whereas late complications include anastomotic
strictures, marginal ulcers, staple line disruption, adhesions, internal
hernias, and dumping syndrome
[1–5].
We report on two patients who developed, respectively, a giant jejunal
ulcer and a long jejunal stricture as the result of chronic ischemia after
gastric bypass surgery. To our knowledge, small-bowel ischemia has not been
described previously in the radiology literature as a complication of this
procedure.
Case Report 1
A 45-year-old woman underwent laparoscopic Roux-en-Y gastric bypass surgery
for morbid obesity. In the immediate postoperative period, the patient had an
episode of prolonged hypotension that responded to treatment with
vasopressors. One day after surgery, she developed acute renal failure
(presumably as a result of ischemia-induced acute tubular necrosis) that
resolved over several days with medical management. Two weeks after surgery,
she was discharged from the hospital in stable condition.
One week after discharge, the patient presented to the emergency department
with nausea, vomiting, and abdominal pain. A single-contrast upper
gastrointestinal tract examination revealed a 3-cm ulcer in the proximal
jejunum abutting the gastrojejunal anastomosis
(Fig. 1A). Endoscopy performed
1 day later confirmed the presence of a giant ulcer with ischemic-appearing
mucosa adjoining the ulcer. Surgery was considered, but because of the
patient's poor medical condition, she was instead treated conservatively with
hyperalimentation and an antisecretory agent. A repeated single-contrast study
performed 3 months later because of continued symptoms revealed a persistent
jejunal ulcer that had decreased in size in the interim
(Fig. 1B). Follow-up endoscopy
performed 3 months later showed a continued jejunal ulcer, and endoscopic
biopsy specimens from the region of the ulcer revealed fibropurulent debris
and hemosiderin deposition. This intractable ulcer was attributed to chronic
jejunal ischemia.
View larger version (97K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A. —45-year-old woman with giant ulcer in jejunum after gastric
bypass surgery. Right posterior oblique spot radiograph from single-contrast
upper gastrointestinal tract study shows 3-cm ulcer (long straight
arrows) in proximal jejunum abutting gastrojejunal anastomosis (short
straight arrow). Note narrowing of anastomosis, most likely related to
edema and spasm associated with ulcer crater. Endoscopy (not shown) confirmed
presence of ulcer with ischemic-appearing mucosa in this region. Also note
gastric pouch (curved arrow).
|
|
View larger version (92K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B. —45-year-old woman with giant ulcer in jejunum after gastric
bypass surgery. Right posterior oblique spot radiograph from follow-up
single-contrast upper gastrointestinal tract study performed 3 months after
A shows 1.5-cm jejunal ulcer (straight arrow). Note gastric
pouch (curved arrow).
|
|
Case Report 2
A 43-year-old woman presented with severe nausea, vomiting, and abdominal
pain 6 weeks after open Roux-en-Y gastric bypass surgery for morbid obesity. A
single-contrast upper gastrointestinal tract examination revealed a 20-cm-long
proximal jejunal stricture that had a smooth contour and tapered borders, with
a short segment of relative sparing in the region of the narrowing
(Fig. 2). The radiographic
findings were believed to be compatible with an ischemic stricture in the
proximal jejunum. The patient underwent an urgent laparotomy with resection of
the diseased jejunal segment and revision of the Roux-en-Y limb. The specimen
obtained at surgery was grossly edematous and ischemic, and findings of
histopathologic specimens revealed chronic ischemia with mucosal ulceration,
fibrinous serositis, crypt distortion, and reactive epithelial change. The
patient had an uneventful recovery and was discharged from the hospital in
satisfactory condition.
View larger version (88K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2. —43-year-old woman with ischemic stricture in jejunum after
gastric bypass surgery. Frontal spot radiograph from single-contrast upper
gastrointestinal tract study shows long segment of tubular narrowing
(arrowheads) in proximal jejunum with smooth contour and effaced
folds. Note short segment of relative sparing (arrow) in region of
narrowing. At surgery, patient was found to have ischemic stricture in
proximal jejunum.
|
|
Discussion
We have described two patients with chronic jejunal ischemia after gastric
bypass surgery. One had a giant ulcer in the proximal jejunum, and the other a
long stricture. To our knowledge, ischemic disease of the small bowel has not
been described previously in the radiology literature as a complication of
this procedure. Nevertheless, it is important to recognize that jejunal
ischemia may be responsible for persistent nausea and vomiting or severe
abdominal pain after gastric bypass surgery and may occasionally necessitate
repeated surgical intervention, as it did in one of our patients.
Our first patient had a jejunal ulcer characterized on a barium study by a
giant ulcer crater in the proximal jejunum abutting the gastrojejunal
anastomosis (Fig. 1A). Marginal
ulcers are known to be a frequent complication of gastric bypass surgery,
occurring in 2–19% of patients
[2]. Such ulcers are almost
always found to arise on the jejunal side of the gastrojejunal anastomosis
[2], and most undergo complete
healing on medical treatment with antisecretory agents
[2]. Marginal ulcers therefore
may be acid-related, developing as a result of repeated exposure of jejunal
mucosa to acid secreted by the gastric pouch, interruption of the normal
gastric acid feedback mechanism, or an underlying ulcer diathesis
[2,
3]. Our patient, however, had a
giant ulcer, and endoscopy revealed mucosal ischemia adjoining the ulcer
crater. Also, the patient's symptoms persisted despite treatment with an
antisecretory agent, and follow-up studies revealed an intractable ulcer that
persisted for at least 6 months (Fig.
1B). These observations provide additional support that the ulcer
was ischemic in origin rather than acid-related.
It has been postulated that tension on the efferent jejunal loop could be a
factor in the development of ischemic ulceration near the gastrojejunal
anastomosis [3]. In our
patient, an episode of prolonged hypotension in the immediate postoperative
period could also have contributed to the jejunal ischemia. Whatever the
pathophysiology, a giant, intractable ulcer in the proximal jejunum abutting
the gastrojejunal anastomosis should raise concern about the possibility of
chronic jejunal ischemia.
Stomal strictures are frequent complications of gastric bypass surgery
[2–5].
These strictures are characterized by short segments of narrowing and
deformity at the gastrojejunal anastomosis
[5]. However, our second
patient had an ischemic jejunal stricture characterized by a long segment of
tubular narrowing with a smooth contour and effaced folds
(Fig. 2). We are aware of no
other reports of an ischemic small-bowel stricture developing after gastric
bypass surgery. In other clinical settings, the differential diagnosis for a
proximal small-bowel stricture includes radiation enteropathy, Crohn's
disease, and infectious enteropathies such as strongyloidiasis
[6]. In a patient who has
undergone gastric bypass surgery, however, chronic ischemia should be a major
consideration for a long, tubular stricture in the proximal small bowel. In
fact, the jejunum may be at greater risk for the development of ischemia after
Roux-en-Y reconstruction because of greater tension on the mobilized jejunal
limb abutting the gastrojejunal anastomosis
[3]. Whatever the cause of the
ischemia, resection of the ischemic segment was required to alleviate the
patient's symptoms.
In conclusion, we have described two patients with chronic jejunal ischemia
occurring as a complication of gastric bypass surgery. One patient developed a
giant, intractable ulcer in the proximal jejunum near the gastrojejunal
anastomosis, and the other a long jejunal stricture. It is important to be
aware of these manifestations of jejunal ischemia after gastric bypass surgery
because some patients may require a repeated laparotomy and resection of the
diseased segment for treatment of their symptoms.
References
- Klein S, Wadden T, Sugerman HJ. AGA technical review on obesity.
Gastroenterology2002; 123:882
–932[Medline]
- Sanyal A, Sugarman HJ, Kellum JM, Engle KM, Wolfe L. Stomal
complications of gastric bypass: incidence and outcome of therapy.
Am J Gastroenterol1992; 87:1165
–1169[Medline]
- Spaulding L. The impact of small bowel resection on the incidence
of stomal stenosis and marginal ulcer after gastric bypass. Obes
Surg 1997;7:485
–487[Medline]
- Byrne TK. Complications of surgery for obesity. Surg
Clin North Am 2001;81:1181
–1193[Medline]
- Blachar A, Federle MP, Pealer KM, Ikramuddin S, Schauer PR.
Gastrointestinal complications of laparoscopic Roux-en-Y gastric bypass
surgery: clinical and imaging findings. Radiology2002; 223:625
–632[Abstract/Free Full Text]
- Rubesin SE, Herlinger H. Small bowel: differential diagnosis. In:
Gore RM, Levine MS, eds. Textbook of gastrointestinal
radiology, 2nd ed. Philadelphia: Saunders, 2000:884
–890
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
T. R. Smith and A. P. White
Narrowing of the Proximal Jejunal Limbs at Their Passage Through the Transverse Mesocolon: A Potential Pitfall of Laparoscopic Roux-en-Y Gastric Bypass
Am. J. Roentgenol.,
July 1, 2004;
183(1):
141 - 143.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Introduction
Case Report 1
