S4637 Upper GI Bleeding Post Roux-en-Y Gastric Bypass

Introduction: Gastrointestinal (GI) bleeding is a rare but serious complication following Roux-en-Y gastric bypass (RYGB) surgery. While early postoperative bleeding is more commonly reported, late-onset bleeding is a much rarer and potentially life-threatening event. Marginal ulcers, occurring at the gastrojejunal anastomosis, are a recognized cause of late GI bleeding. We discuss a 38-year-old man presenting with significant GI bleeding 4 years post-RYGB. Case Description/Methods: A 38-year-old man who presented with upper GI bleeding 4 years post-RYGB. He had a history of chronic alcohol use. The patient experienced melena for a week. Upon admission, he was stable, and laboratory findings revealed a hemoglobin level of 9.8 g/dL, white blood cell count of 5.2, platelet count of 294, and an international normalized ratio (INR) of 1.16. His Glasgow-Blatchford score was 10, signaling a high risk for GI bleeding. Computed tomography imaging showed diffuse fatty liver infiltration, mild non-specific panniculitis, and prior bariatric surgery changes. Endoscopic evaluation confirmed a gastrojejunal ulcer at the anastomosis site, displaying congestion, edema, erythema, and ulceration. Endoscopy revealed a Roux-en-Y gastrojejunostomy ulcer with congestion and erythema at the gastrojejunal anastomosis. Hemostasis was achieved via: epinephrine injection (4 mL, 0.2 mg/mL), placement of 2 hemostatic clips and hemostatic spray application. A unit of packed red blood cells was transfused. The patient tested positive for H. pylori and was discharged on quadruple therapy with outpatient follow-up. Discussion: GI bleeding post RYGB can be early (1-4% incidence) or late (>30 days). Typically arises from marginal ulcers at the gastrojejunal site which account for 0.6 to 16% of cases. Risk factors include smoking, nonsteroidal anti-inflammatory drug use, diabetes, and H. pylori infection. Late bleeding sources include the Roux limb (hematochezia) or gastric remnant/duodenum (melena). Alcohol use disorder in our patient likely increased his chance. Late GI bleeding following RYGB, although rare, is potentially life-threatening. Timely endoscopic intervention combined with long-term medical management is essential for recurrence prevention. Identifying marginal ulcers and understanding risk factors remain crucial for optimizing patient outcomes.