S3542 Ulcerative Roux Limb Jejunitis: Unusual Finding on Endoscopy

Abstract

INTRODUCTION: Obesity is a common health issue in the United States. Roux-en-Y Gastric Bypass (RYGB) is most frequently performed in the US. Although, it has promising effects on weight loss but overall complication rate is 21% (1). We present a unique case of ulcerative roux limb jejunitis. CASE DESCRIPTION/METHODS: 38 y/o female with a history of RYGB 13 yrs ago presented with LUQ abdominal pain and dark stools of one day's duration. She took Motrin and drank a large quantity of alcohol 4 days prior to presentation. Subsequently, she began been having intermittent LUQ abdominal discomfort with loss of appetite and nausea. She had no history of GI bleed. Her last endoscopy and colonoscopy in 2015 were normal. She smokes cigarettes 1 PPD, is a social drinker, and has no history of IVDA. Abd exam was positive for LUQ tenderness but no rebound tenderness. DRE was negative for melena. Labs showed Hb 14.8, BUN/Cr 5/0.5, AST/ALT 153/121, lipase 1053, lactic acid 2.3, vit B12 169, ANA/ASMA/ESR/viral hepatitis panel/EtOH/fibrin split products/UDS normal. CT abdomen pelvis with IV contrast showed bowel wall thickening and inflammatory change surrounding the loop of bowel emanating from the bypass. Esophagogastroduodenoscopy (EGD) showed inflammation involving the gastric pouch and extending from the gastrojejunal anastomosis (at 45 cm) to involve almost the entire roux limb (about 35 – 40 cm in length). It was characterized by marked edema, erythema, friable mucosa with erosion and ulceration. There was a short afferent limb with inflammation. The jejunojejunal anastomosis was normal at about 90cm. Biopsies were taken and histopathology showed acute inflammation. Based on the EGD findings, ischemia was a concern but CTA abdomen and pelvis were unremarkable. Her Hb remained stable during the hospital course and she was discharged with outpatient follow up with GI and surgery. DISCUSSION: RYGB is associated with early and late postoperative complications which include anastomotic leak, ileus, GI tract hemorrhage, anastomotic stricture, bowel obstruction, intussusception, and marginal ulceration. However, extensive jejunitis both involving the entire roux limb and confined to the roux limb has rarely been reported. NSAID and heavy alcohol consumption were thought to be the culprit in light of negative CTA abdomen.Figure 1.: GastroJejunal Anastomosis showing friable mucosa, ulceration, erosions, and extensive inflammation.Figure 2.: Roux limb showing extensive inflammation and hemorrhagic appearance.Figure 3.: Roux limb showing extensive inflammation.