INTRODUCTION: While peptic ulcers can occur after Roux-en-Y gastric bypass surgeries, they are most commonly found as marginal ulcers at the gastrojejunal anastomosis and amenable to standard endoscopy. Peptic ulcers that occur in the gastric remnant and duodenum are less common and pose significant diagnostic and therapeutic challenges due to their inability to be accessed by esophagogastroduodenoscopy (EGD). We report one such case of a woman who presented with CT findings suggestive of a gastric remnant ulcer who underwent laparoscopic assisted endoscopy of gastric remnant and duodenum.

CASE DESCRIPTION: A 53-year-old female who underwent a Roux-en-Y gastric bypass nine years prior presented to clinic with three weeks of sharp post-prandial abdominal pain radiating to the back. CT imaging of the abdomen was suspicious for inflammation and a possible ulcer in the anterior antrum of the gastric remnant without any free air. She was placed on a proton pump inhibitor by gastroenterology and then referred to surgery as this area was not accessible by EGD secondary to her gastric bypass. The patient subsequently underwent a laparoscopic lysis of adhesions, laparoscopic assisted endoscopy of gastric remnant and duodenum, and upper endoscopy of esophagus, gastric bypass, and distal extent of roux limb. She was discovered to have a duodenal ulcer. Biopsies taken from the gastric antrum and duodenum were negative for Helicobacter pylori or malignancy.

DISCUSSION: Morbid obesity is a debilitating illness that has resulted in a growing volume of bariatric surgery. Sleeve gastrectomy and Roux-en-Y gastric bypass are the two most predominate weight loss surgeries performed currently in the United States. Proficiency in evaluating and treating complications of Roux-en-Y gastric bypass is imperative for management of bariatric patients, which includes evaluation for peptic ulcers and other pathology in the gastric remnant and duodenum. Endoscopy evaluation of the gastric remnant and duodenum cannot be performed trans-orally. This case demonstrates a laparoscopic assisted trans-gastric access for endoscopic evaluation of the duodenum and gastric remnant for peptic ulcer disease.