Marginal Ulcers. Marginal Ulcers. Gastric Remnant Ulcers. Double Balloon Enteroscopy. Marginal Ulcer. Gastrojejunal Stricture.

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1 Upper Abdominal Pain in the Bariatric Surgery Patient Martin L. Freeman, M.D., FASGE,FACG Professor of Medicine Director, Pancreaticobiliary Endoscopy Fellowship Interim Director, Division of GI, Hepatology and Nutrition Medical Director, Total Pancreatectomy / Islet AutoTransplantion University of Minnesota Minneapolis, Minnesota [email protected] Diagnostic approach to Abdominal Pain Careful history Timing after surgery Perioperative 3 months > 6 months Character of pain Constant (ulcer, pancreatic) Crampy, intermittent (obstruction, biliary) Diagnostic approach to Abdominal Pain Labs Liver and pancreatic enzymes, CBC, sed rate Imaging US CT SBFT MRCP HIDA MRCP +/- Secretin MRCP w Secretin Incisional Pain Timeline for Pain after Gastric Bypass Biliary Disease Internal Hernia Gastritis Marginal Ulcer Surgery 3 months 6 months 1 year Leaks Anastomotic Stricture Adhesions Functional Wound Infection Broad Differential for Abdominal Pain Right upper quadrant: Hepatitis Cholecystitis Cholangitis Pancreatitis Budd-Chiari syndrome Pneumonia Empyema Pleurisy Subdiaphragmatic abscess Right lower quadrant: Appendicitis Salpingitis Ectopic pregnancy Inguinal hernia Nephrolithiasis Inflammatory bowel disease Mesenteric adenitis (yersina) Epigastric: Peptic ulcer disease Gastroesophageal reflux disease Gastritis Pancreatitis Myocardial infarction Pericarditis Ruptured aortic aneurysm Periumbilical: Early appendicitis Gastroenteritis Bowel obstruction Ruptured aortic aneurysm Left upper quadrant: Splenic abscess Splenic infarct Gastritis Gastric ulcer Pancreatitis Left lower quadrant: Diverticulitis Salpingitis Ectopic pregnancy Inguinal hernia Nephrolithiasis Irritable bowel syndrome Inflammatory bowel disease Diffuse Gastroenteritis Mesenteric ischemia Metabolic (eg, DKA, porphyria) Malaria Familial Mediterranean fever Bowel obstruction Peritonitis Irritable bowel syndrome Common Causes of Pain after Gastric Bypass Marginal Ulcer Biliary Pancreatic Disease Functional Gastrojejunal Stricture Obstruction 1

2 Marginal Ulcer 1% to 16% Often early post op Nausea, vomiting, pain, dysphagia, bleeding Continuous Not necessarily related to PO intake Marginal Ulcers Tension, ischemia, foreign body, H.pylori, outlet obstruction, smoking, NSAIDS, larger pouch Upper endoscopy Marginal Ulcers PPI, H2 blockade, +/- sucralfate Eradicate H.pylori Treat for 6 to 8 weeks Cessation of NSAIDs and smoking Endoscopic confirmation of healing Resection and revision for refractory ulcers Problematic! Double balloon IR or Surgery Transgastric endoscopy? Gastric Remnant Ulcers Double Balloon Enteroscopy Endoscopic access to bypassed stomach ERCP? Gastrojejunal Stricture Onset 3 to 10 weeks post op Pain, nausea and vomiting Dysphagia to solids > liquids 5-10 minutes after PO intake 2

3 Gastrojejunal Strictures Bowel Obstruction Ischemia, ulcers Subclinical anastomotic leaks Gastrograffin UGI Endoscopy +/- dilatation 1% to 3% after open gastric bypass Higher in lap bypass Adhesions (open), internal hernias (lap), anastomotic strictures, intussusception, volvulus Internal Hernia 1-4.7% after open bypass Higher in lap bypass Intermittent epigastric, LUQ, radiates to back Mild to severe minutes post prandial Internal Hernia CT scan or upper gastrointestinal contrast study 20% miss rate Consider diagnostic laparoscopy Reduction of the herniated bowel Closure of the hernia space Closed loop obstruction Rare (0.6%) Kink or stenosis of anastomosis Severe unrelenting epigastric pain, hiccups Most often perioperative Obstructive jaundice Closed Loop obstruction CT shows dilated gastric remnant and duodenum Reduction of the underlying biliary limb obstruction Consider temporary percutaneous gastrostomy tube decompression 3

4 Biliary Disease 50% rate of gallbladder sludge formation 6 months after gastric bypass 3% to 30% symptomatic gallbladder disease Postprandial (few hours) right upper quadrant pain radiating to the back > 6 months post operative Biliary Disease Prophylactic Cholecystectomy? Pros: High likelihood of sludge or stones after GBP May be more difficult later (esp. ERCP!) Cons: Increase procedure time minutes May increase LOS Ursodiol? Pros: Biliary Disease 600 mg of ursodiol daily for 6 months decreased the rate of gallstone formation from 32% to 2% Cons: Poor compliance Cost Biliary Disease Intraoperative or trans abdominal ultrasound WBC, LFTs CT MRCP HIDA Cholecystectomy ERCP Evaluation prior to ERCP ERCP after Gastric Bypass MRCP first to ensure good indication! Clear indication for ERCP Review surgical anatomy MRCP usually recommended EUS often not feasible or limited Any anatomy with altered stomach Gastric bypass Banded gastroplasty MRCP ERCP 4

5 Technique for Transgastric ERCP Laparoscopic Gastrostomy for ERCP Laparoscopic access to bypassed stomach Large laparoscopic port (> 12 mm ID) placed into gastric lumen Duodenoscope passed through port and standard ERCP performed Closure performed after ERCP If repeat access needed, a 30 Fr PEG tube left in place* ERCP after RYGBP for pancreatitis with pancreas divisum ERCP up a Roux-Limb Rotatable papillotome MRCP with secretin minor papillotomy 12 o clock 9 o clock 6 o clock ERCP up a Roux-Limb Functional Pain Guidewire cannulation correct incorrect Irritable bowel Visceral hyperalgesia Spastic bowel Nonulcer dyspepsia Non specific motility disorder 5

6 Rome III Criteria for IBS Recurrent pain >3 d/mo in 3 months, associated with >2 of following Improvement with defecation Onset associated with change of stool frequency Onset associated with change in stool appearance Watch for warning signs Thorough workup Medical Management of Functional Pain Treat constipation Empiric PPI, +/- H2 blocker Amitriptyline (10-75 mg) 2 RCTs SSRI? Dicyclomine? Gabapentin or Pregabalin (Lyrica)? Avoid narcotics and NSAIDS! Nausea and vomiting Pain after Banded Gastroplasty Common complaint following the initiation of a soft diet Most common first few months after surgery Overeating Not chewing food properly Consider other causes Less invasive than GBP Same periop pain as lap cholecystectomy Less weight loss Potential complications Band slippage Erosion Endoscopy and ERCP is possible after VBG 7mm Peds duodenoscope 6