P2059 - Late Gastric Perforation of the Bypassed Stomach Sixteen Years After Roux-en-Y Gastric Bypass

Seyma Bayram, MD¹, Mehmet Talha Bayram, MD², Elmkdad Mohammed, MD¹, Udit Asija, MD³, Omar Alkasabrah, MD⁴, Ali Osman Avci, MD⁵, Hamza Saber, MD¹
1The Wright Center for Graduate Medical Education, Scranton, PA; 2Geisinger Wyoming Valley Medical Center, Wilkes-Barre, PA; 3The Wright Center for Graduate Medical Education, Throop, PA; 4Landmark Medical Center, Woonsocket, RI; 5Lokman Hekim University Ankara Hospital, Ankara, Ankara, Turkey

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 male 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 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 CT 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 six.

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.

Disclosures:
Seyma Bayram indicated no relevant financial relationships.
Mehmet Talha Bayram indicated no relevant financial relationships.
Elmkdad Mohammed indicated no relevant financial relationships.
Udit Asija indicated no relevant financial relationships.
Omar Alkasabrah indicated no relevant financial relationships.
Ali Osman Avci indicated no relevant financial relationships.
Hamza Saber indicated no relevant financial relationships.

Seyma Bayram, MD¹, Mehmet Talha Bayram, MD², Elmkdad Mohammed, MD¹, Udit Asija, MD³, Omar Alkasabrah, MD⁴, Ali Osman Avci, MD⁵, Hamza Saber, MD¹. P2059 - Late Gastric Perforation of the Bypassed Stomach Sixteen Years After Roux-en-Y Gastric Bypass, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.