1. 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: , W7.

2. 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~

3. 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.

4. ABDOMINAL CT Ascites with peritoneal fat stranding and thickening.
Mild GB distention.
Initial Impression: Acute cholecystitis, suspect peritonitis.
ABDOMINAL CT
1st ROW: , 2nd row: , ,
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.

5. 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

6. 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.

7. 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.

8. 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

9. 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.

11. 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!

12. 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.

13. THANK YOU FOR YOUR ATTENTION 謝謝聆聽 敬請指教