Daniel Mai, MD1, Bryant Le, MD1, Nicholas Totah, MD1, Yuri Kwon, MD, MPH2, Suhail Sidhu, MD1, Amirali Tavangar, MD3, Peter H. Nguyen, MD2, Carlos Saad, MD3, Gregory Albers, MD, FACG1, Christina Ling, MD1 1University of California Irvine, Orange, CA; 2University of California Irvine Health, Orange, CA; 3University of California Irvine Digestive Health Institute, Orange, CA Introduction: Nissen fundoplication is a well-established surgical intervention for gastroesophageal reflux disease (GERD) refractory to medical treatment. Although generally safe, complications include dysphagia, gas-bloat syndrome, and recurrent heart burn. Gastric ulceration after fundoplication is a rare complication especially when occurring outside typical sites such as the upper lesser curvature or gastric cardia. We report a case of obscure gastrointestinal bleeding due to superficial ulcers located near the outer aspect of the fundoplication wrap.
Case Description/
Methods: A 60-year-old woman with a history of GERD status-post Nissen fundoplication in 2004 and suppurative cholangitis status post combined partial hepatic lobectomy and Roux-en-Y hepaticojejunostomy in 2014 presented with two episodes of melena and symptomatic anemia. She had a prior history of NSAID-induced ulcers in 2023 but denied recent use. Esophagogastroduodenoscopy (EGD) revealed an intact Nissen wrap and normal esophagogastric landmarks. On retroflexion, three superficial non-bleeding gastric ulcers with clean bases (Forrest Class III) were identified on the outer surface of the fundoplication wrap (Figure 1A and 1B). The largest lesion measured 4–5 mm and was intermittently obscured by surrounding folds. No ulcers were identified in the body, antrum, fundus, or angularis. Old clots were noted in the fundus without signs of bleeding from distal anastomosis. Biopsies obtained for Helicobacter pylori testing were negative. The patient was treated medically and repeat EGD two months later showed ulcer resolution. Discussion: This case represents a rare presentation of post-fundoplication gastric ulceration. While most reported cases involve ulcers near the cardia or upper lesser curvature, our case highlights ulceration occurring on the outer surface of the fundoplication wrap that is seldom documented. Potential contributing factors include altered vascular supply secondary to prior hepatic surgery which may affect perfusion of the gastric fundus. The absence of other mucosal lesions supports a localized mechanism such as mechanical or vascular changes inherent to the surgical wrap. Negative H. pylori status in this patient further supports a non-infectious, structural etiology. Endoscopic detection requires meticulous retroflexion and attention to blind spots obscured by the wrap configuration.
Figure: Figure 1A: Fundoplication ulcer (outer aspect of fundoplication wrap) noted at gastric cardia
Figure 1B: Multiple erosions and ulcers at gastric cardia
Disclosures: Daniel Mai indicated no relevant financial relationships. Bryant Le indicated no relevant financial relationships. Nicholas Totah indicated no relevant financial relationships. Yuri Kwon indicated no relevant financial relationships. Suhail Sidhu indicated no relevant financial relationships. Amirali Tavangar indicated no relevant financial relationships. Peter Nguyen indicated no relevant financial relationships. Carlos Saad indicated no relevant financial relationships. Gregory Albers: Nestle Pharmaceuticals – Speakers Bureau. Christina Ling indicated no relevant financial relationships.
Daniel Mai, MD1, Bryant Le, MD1, Nicholas Totah, MD1, Yuri Kwon, MD, MPH2, Suhail Sidhu, MD1, Amirali Tavangar, MD3, Peter H. Nguyen, MD2, Carlos Saad, MD3, Gregory Albers, MD, FACG1, Christina Ling, MD1. P5248 - Hidden in the Fold: A Rare Case of Gastric Ulcers on a Fundoplication Wrap, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.
