Diagnosis of Remnant Gastric Ulcer Perforation After RYGB is Challenging, Peritonitis without Pneumoperitoneum: A case report. Presented by Dr. 李卓勳 / SCOTT Supervisor: Dr. 陳仁隆 Department of General Surgery E-Da Hospital. Date: 2019-03-17, W7.

THE CASE 22-year-old woman has following history: Morbid obesity & fatty liver S/P laparoscopic Roux-en-Y gastric bypass on 2010/01/11. Internal herniation through Peterson defect S/P laparoscopic adhesionolysis and bowel reduction on 2015/08/03. C/C: Intermittent abdominal pain for 1 week with progression. Epigastric and RUQ pain/cramping. (-)vomiting, (-)diarrhea. PE: RUQ tenderness with rebounding. Lab: leukocytosis(WBC:16.6x109/l), elevated CRP(67mg/l), lipase (709 u/l). Imp: peritonitis, acute cholecystitis, suspect pancreatitis. 7/14,15,16: conservative management failed 7/17: operation~

Clear lung field, bilaterally. No pleural effusion. Kidney, Ureter, Bladder Supine Fecal Retention in Colon. Small calcification noted in pelvic cavity, Ddx: phleboliths or tiny urolithiasis. Status post intrauterine device insertion. Mild degenerative change of lumbar spine. Mild scoliosis. Clear lung field, bilaterally. No pleural effusion. No free air/pneumoperitoneum Fecal retention in colon Suspect ileus.

ABDOMINAL CT Ascites with peritoneal fat stranding and thickening. Mild GB distention. Initial Impression: Acute cholecystitis, suspect peritonitis. ABDOMINAL CT 1st ROW: 101-109, 2nd row: 111-119, 121-129, 131-139 Abdominal CT Axial view reading from Left to Right , Top to Bottom showed that... - Ascites with Peritoneal fat stranding and thickening : PERITONITIS considered. - Mild GB distention. - Initial Impression: Acute cholecystitis, suspect peritonitis.

COURSE OF ILLNESS 2018/07/14 Visit ER: Epigastric/RUQ pain. Initial Impression: stable vitals. Acute cholecystitis. Acute pancreatitis Suspect Peritonitis. Laparoscopic RYGB on 2010/01/11 RYGB： Roux-en-Y Gastric Bypass. • “peritoneal signs” – Rebound tenderness – Tenderness to percussion – Involuntary guarding Laparoscopic adhesionolysis & bowel reduction on 2015/08/03 Admit for Antibiotics. NPO, IVF Pain control No improvement! 2018/07/18 Laparoscopic exploration/ cholecystectomy… COURSE OF ILLNESS

LAPAROSCOPIC... Exploration Postop Dx: Perforated peptic ulcer over antrum. Bile ascites: 1000ml Collapsed GB w/ NL appearance. One perforated peptic ulcer 1cm over antrum, upper side. Mild adhesion of small bowel. OP: Simple closure of PPU interrupted 3 stitches. 1 JP in SUBHEPATIC space. One 1cm perforated peptic ulcer over the antrum  Simple closure Collapsed GB ĉ normal appearance.

Postoperative / Final Diagnosis Morbid obesity S/P roux-en-Y gastric bypass. Remnant gastric ulcer perforation. Peritonitis Smooth recovery 2018/07/21 Discharged. Laparoscopic RYGB on 2010/01/11 Laparoscopic adhesionolysis & bowel reduction on 2015/08/03 2018/07/14 Visit ER: Epigastric/RUQ pain. Initial Impression: stable vitals. Acute cholecystitis. Acute pancreatitis Suspect Peritonitis. Admit for Antibiotics. NPO, IVF Pain control No improvement! 2018/07/18 Laparoscopic exploration/ cholecystectomy… Perforated Remnant Gastric Ulcer. Acute peritonitis.

DISCUSSION INCIDENCE: RARE LEFT: Followed 4300 patients after RYGB and found 11 perforations. RIGHT: follow 360 pts: only 3 had perforation Conclusion: Incidence appears to be RARE

DISCUSSION Even in this case series and review: 1883 RYGB were followed. This paper present short case series of perforated DU in pts s/p RYGB. Roux-en-Y gastric bypass(RYGB): bariatric procedure; Biliopancreatic limb: NO contain swallowed air! Purpose: present short case series of perforated duodenal ulcers in pts s/p RYGB.

DISCUSSION 4 patients: (+) cross sectional imaging studies; only 1 (+) free air, but 4(+)free fluid! Pneumoperitoneum rare, but free fluid: common. 4 cases (+)bilious fluid found on exploration. In normal anatomy with perforated ulcers: 82% (+) pneumoperitoneum. Only 2 (+) elevated WBC; WBC can be normal 3 (+)elevated LIPASE  2 misdiagnosed pancreatitis; 2 (+)H. pylori, empirical Triple therapy was given since DU as we know were highly associated with H.P. infections. 3 /23 previous (+)free air: maybe b/c refluxed air from alimentary limb. (+)free fluid in previous RYG patient: alert bariatric surgeon to possibility of perforation of bypassed limb! Hepatobiliary scintigraphy: can also be considered to detect actively leaking perforation!

TAKE HOME MESSAGE Perforated "remnant" gastric ulcer post-RYGB is rare; Diagnosis is challenging; high suspicion for general peritonitis with intraabdominal free fluid. Past literature: Hallmark for perforated peptic ulcer post RYGB: general peritonitis without pneumoperitoneum. Ascites aspiration: (+)bilious fluid may help confirm diagnosis. Laparoscopic repair is feasible with good outcome.

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