S4700 Vonoprazan as Salvage Therapy in Recalcitrant Gastro-Jejunal Marginal Ulcer

Introduction: In patients with roux-en-y gastric bypass, recalcitrant marginal ulcers may persist in 3.9% of cases even after medical therapy. Failure of medical therapy typically require further invasive procedures such as endoscopic suturing or surgical revision, with morbidity and complications as high as 60%. In this case, we present vonoprazan, a potassium competitive acid blocker, used as salvage therapy to treat a recalcitrant marginal ulcer, avoiding further invasive procedures. Case Description/Methods: A 76-year-old woman with a history of Roux-en-Y-gastric bypass presented to the emergency department complaining of coffee ground emesis, epigastric abdominal pain and shortness of breath for the past 3 days. Initial vital signs showed hypotension and tachycardia. Hemoglobin showed a decrease from a baseline of 10.1 g/dL to 6.5 g/dL. She was admitted to the intensive care unit. The patient had a known history of gastrojejunal anastomotic ulcer 2 years prior that had responded to open capsule esomeprazole 40 mg twice daily, sucralfate 1 gram 4 times daily, and was healed as of 8 months prior. She had been continued on esomeprazole 40 mg twice daily in addition to sucralfate 1 gram twice daily. Of note, patient had recently been taking meloxicam as needed for chronic back pain. During the present admission, an upper endoscopy was performed and showed deep ulceration (Forrest III) at the gastrojeunal anastomosis. After 2 days of medical therapy with pantoprazole 40 mg intravenous twice daily, no further bleeding was noted. The patient was discharged with plans to follow up with bariatric surgery for consideration of gastric bypass revision. In addition, Vonoprazan 20 mg daily was added to the patient’s regimen, and she discontinued meloxicam. Five weeks later, a repeat esophagogastroduodenoscopy showed resolution of gastrojejunal marginal ulcer and a healthy appearing gastrojejunal anastomosis. Discussion: Despite being on therapy with open capsule esomeprazole 40 mg twice daily and sucralfate 1 gram 4 times daily, the patient had deep ulceration that otherwise may have required invasive endoscopic procedures or revision surgery. The addition of vonoprazan, which has a different mechanism and superior efficacy compared to proton pump inhibitors, prevented the patient from further invasive procedures, including the possibility of revision surgery.