Late gastrointestinal hemorrhage after gastric bypass

Background: Hemorrhage from the excluded gastric segment or duodenum after gastric bypass is an uncommon late complication and poses both diagnostic and therapeutic difficulties. We describe 4 cases of late gastrointestinal (GI) hemorrhage after gastric bypass. Methods: 4 patients who underwent previous Roux-en-Y gastric bypass (RYGBP) presented for management of severe GI hemorrhage. Their history, diagnostic work-up, management, and surgical pathology are reviewed. Results: In all 4 patients, preoperative diagnostic evaluation including nuclear scintigraphy, endoscopy, and angiography failed to localize the source of bleeding. Intraoperative endoscopy of the gastric remnant and subtotal gastrectomy were performed in all 4 patients. The mean time interval between RYGBP operation and gastrectomy was 15.5 years (range 13-17 years). In 3 of 4 patients, the source of bleeding was documented on pathologic examination of the resected gastric remnant and duodenum. At a mean follow-up of 15 months, none of the patients developed recurrent GI hemorrhage. Conclusion: GI hemorrhage after RYGBP can be a diagnostic and therapeutic dilemma. Intraoperative endoscopy of the excluded stomach and subtotal gastrectomy should be considered when the source of bleeding is not identified by conventional diagnostic techniques.