S4795 Hidden in the Fold: A Rare Case of Gastric Ulcers on a Fundoplication Wrap

Introduction: Nissen fundoplication is a well-established surgical intervention for gastroesophageal reflux disease (GERD) refractory to medical treatment. Although generally safe, complications include dysphagia, gas-bloat syndrome, and recurrent heart burn. Gastric ulceration after fundoplication is a rare complication especially when occurring outside typical sites such as the upper lesser curvature or gastric cardia. We report a case of obscure gastrointestinal bleeding due to superficial ulcers located near the outer aspect of the fundoplication wrap. Case Description/Methods: A 60-year-old woman with a history of GERD status-post Nissen fundoplication in 2004 and suppurative cholangitis status post combined partial hepatic lobectomy and Roux-en-Y hepaticojejunostomy in 2014 presented with 2 episodes of melena and symptomatic anemia. She had a prior history of nonsteroidal anti-inflammatory drug-induced ulcers in 2023 but denied recent use. Esophagogastroduodenoscopy (EGD) revealed an intact Nissen wrap and normal esophagogastric landmarks. On retroflexion, 3 superficial non-bleeding gastric ulcers with clean bases (Forrest Class III) were identified on the outer surface of the fundoplication wrap. The largest lesion measured 4–5 mm and was intermittently obscured by surrounding folds. No ulcers were identified in the body, antrum, fundus, or angularis. Old clots were noted in the fundus without signs of bleeding from distal anastomosis. Biopsies obtained for Helicobacter pylori testing were negative. The patient was treated medically and repeat EGD 2 months later showed ulcer resolution. Discussion: This case represents a rare presentation of post-fundoplication gastric ulceration. While most reported cases involve ulcers near the cardia or upper lesser curvature, our case highlights ulceration occurring on the outer surface of the fundoplication wrap that is seldom documented. Potential contributing factors include altered vascular supply secondary to prior hepatic surgery which may affect perfusion of the gastric fundus. The absence of other mucosal lesions supports a localized mechanism such as mechanical or vascular changes inherent to the surgical wrap. Negative H. pylori status in this patient further supports a non-infectious, structural etiology. Endoscopic detection requires meticulous retroflexion and attention to blind spots obscured by the wrap configuration.