Neelam Khetpal, MD1, Adalberto Gonzalez, MD2 1Cleveland Clinic Florida, Weston, FL; 2Cleveland Clinic Florida, Boca Raton, FL 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 Female 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 three 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 two years prior that had responded to open capsule esomeprazole 40 mg twice daily, sucralfate 1 gram four times dailiy, and was healed as of eight 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 (Figure 1). After 2 days of medical therapy with pantoprazole 40 mg IV 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 EGD 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 four 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.
Figure: Figure 1. A marginal ulcer is seen at the gastro-jejunal anastomosis.
Figure: Figure 2. The previous area of marginal ulceration has healed.
Disclosures: Neelam Khetpal indicated no relevant financial relationships. Adalberto Gonzalez indicated no relevant financial relationships.
Neelam Khetpal, MD1, Adalberto Gonzalez, MD2. P3086 - Vonoprazan as Salvage Therapy in Recalcitrant Gastro-Jejunal Marginal Ulcer, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.
