S2898 A Unique and Challenging Presentation of Abdominal Pain in Patient of Gastric Bypass Anatomy

Abstract

Introduction: We are presenting an interesting and challenging case of chronic abdominal pain in a patient of gastric bypass surgery. This patient required Endoscopic ultrasound (EUS) directed transgastric Endoscopy (EDGE) for diagnosis and management of pyloric stenosis in a patient with Roux-en-Y gastric bypass anatomy. Case Description/Methods: 61 years old female presented to emergency department with worsening upper abdominal pain for last 2 years. Patient has history of Roux-en-Y gastric bypass surgery in 2002. Patient had multiple prior evaluations with endoscopies and imaging without any significant etiology identified. She underwent repeat endoscopy with finding of a short gastric pouch and normal-appearing gastrojejunal anastomosis and jejunal limbs. An upper gastrointestinal series and small-bowel follow-through showed normal anatomy. A computed tomography of the abdomen significantly distended bypassed stomach (BS) with fluid. Upon further discussion with Radiology, there was abnormal thickening and elongation of the gastric pylorus noted. Subsequently, an EUS directed transgastric endoscopy was performed revealing significantly dilated BS. An AXIOS stent was placed between gastric pouch and BS in order to decompress as well as gaining access to pyloric channel. Tract was dilated and entered with regular gastroscope. Excessive amount of fluid was aspirated from stomach. A severe friable stenosis found at pylorus. This was only traversed with XP190N gastroscope with outer diameter of 5.4mm. Pathology showed benign inflammation. Repeat EGD was performed through the established tract. Pyloric stricture was then dilated up to 12 mm. Patient was subsequently discharged in stable condition and followed up in clinic. She reported significant improvement in symptoms. Discussion: Despite its overall benefit, there are multiple complications associated with Roux-en-Y gastric bypass. EDGE procedure has been routinely performed in order to gain access to biliary tract. Options to gain access to BS include laparoscopic assisted endoscopy versus surgical exploration. EDGE not only provided therapeutic benefit of decompressing significantly distended excluded stomach but also provided access for examining pyloric channel stenosis/thickening concerning for inflammation or neoplasm. After confirming benign nature, repeated endoscopy was performed for dilation. To our knowledge, this is among first few cases of minimally invasive management of gastric outlet obstruction in patient with gastric bypass anatomy.