S6247 Late Gastric Perforation of the Bypassed Stomach Sixteen Years After Roux-en-Y Gastric Bypass

Introduction: Refractory morbid obesity is a major health problem in the United States. Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has become a widely accepted surgical intervention for its treatment. Although associated with reduced long-term morbidity, complications involving the bypassed stomach, such as peptic ulcer disease and perforation, are rare but serious. Gastric perforation occurring in the bypassed (remnant) segment of the stomach following RYGBP is extremely rare, with an estimated incidence of approximately 0.3%. We report a case of gastric perforation secondary to peptic ulcer disease occurring 16 years after the initial surgery. Case Description/Methods: A 64-year-old man with a history of gastric bypass surgery performed 16 years earlier presented with acute abdominal pain, nausea, vomiting, and melena. He was hypotensive and tachycardic on arrival. Physical examination revealed abdominal distension and rebound tenderness. Laboratory findings showed a hemoglobin level of 6.5 g/dL and elevated lactic acid. A 12-lead electrocardiogram (ECG) demonstrated ST-segment elevations in the inferior leads; however, bedside echocardiography revealed a normal ejection fraction (55%–60%) with no wall motion abnormalities. Point-of-care ultrasound identified free intraperitoneal fluid, and a computed tomography scan of the abdomen and pelvis confirmed pneumoperitoneum suggestive of a perforated viscus. One unit of packed red blood cells (PRBCs) was transfused in the Emergency Department for initial stabilization. The patient underwent emergent exploratory laparotomy, which revealed a perforated gastric ulcer in the bypassed stomach, distant from the anastomotic site. Primary repair of the perforation was performed. Postoperative recovery was uneventful, with rapid clinical improvement. A repeat ECG showed resolution of the prior ST-segment changes, confirming a non-cardiac cause. The patient was discharged on postoperative day 6. Discussion: The inaccessibility of the bypassed stomach poses significant diagnostic challenges. This case highlights the importance of maintaining a high index of suspicion for perforated gastric ulcers in post-RYGBP patients presenting with acute abdomen. Prompt imaging and surgical exploration are critical for diagnosis and definitive management. Late gastric perforation of the excluded stomach should remain a differential consideration in post-RYGBP patients presenting with acute abdomen. Early surgical intervention is key to favorable outcomes.