S2191 Endoscopic and Medical Management of Actinomycosis Infection at the Gastro-Jejunal Anastomosis After Subtotal Gastrectomy With Roux-en-Y Reconstruction Resolves Chronic Abdominal Pain

Abstract

Introduction: Roux-en-Y gastric bypass surgery (RYGB) is one of the most common type of gastric surgeries performed worldwide. Chronic post-operative abdominal pain post RYGB occurs in up to 30% of patients. We present an 82-year-old female with chronic abdominal pain post RYGB caused by actinomycosis infection at gastrojejunal anastomosis associated with suture material. Case Description/Methods: An 82-year-old female presented with persistent epigastric abdominal pain following subtotal gastrectomy with Roux-en-Y reconstruction for stage 1 gastric adenocarcinoma. She reported chronic abdominal pain within a year of surgery. Imaging with CT abdomen/pelvis was unremarkable and EGD demonstrated a marginal ulcer. She was started on PPI but abdominal pain worsened, requiring multiple hospitalizations, repeated imaging and endoscopies over the next 5 years following surgery without an identified etiology for her ongoing abdominal pain. Repeat EGD at our center showed resolution of marginal ulcer and nodularity at the gastrojejunal anastomosis with associated suture material. Biopsies of the nodule demonstrated Actinomycosis infection with acute inflammatory exudate. She was started on amoxicillin and repeat EGD was performed with removal of suture material using endoscopic suture cutters. Repeat biopsy confirmed Actinomyces infection of the anastomosis as well as colonization of suture material. Antibiotics were continued for a total of six months and her abdominal pain completely resolved. Repeat EGD after completion of therapy demonstrated no evidence of actinomycosis infection at the anastomosis. Discussion: Actinomycosis infection following RYGB surgery is an uncommon source of post-operative chronic abdominal pain. In our case, increase in gastric pH after RYGB surgery due to anatomical changes and PPI usage as well as retained suture likely predisposed to this infection. There may have been a delay in diagnosis due to difficulty in visualizing the suture material on repeat EGD as it was located behind a fold of the anastomosis. This reinforces the recommendation for careful inspection of the post-RYGB anastomosis when evaluating chronic post-operative abdominal pain. Prior cases of intra-abdominal Actinomyces infection after RYGB required prolonged antibiotics for greater than 12 months or surgical intervention. To our knowledge, this is the first reported case of Actinomyces at the gastrojejunal anastomosis successfully treated with endoscopic foreign body removal and six months of antimicrobials.