Endoscopic Ultrasound-Guided Gastric Remnant Access for Massive Upper Gastrointestinal Bleeding in Roux-en-Y Anatomy

ABSTRACT

This case reports a novel and successful attempt at identifying and treating massive upper gastrointestinal bleeding in an unstable patient with Roux-en-Y anatomy via endoscopic ultrasound-directed transgastric intervention and over-the-scope clip placement. The remnant stomach was located under endoscopic ultrasound and accessed via gastrogastrostomy, which was created via lumen-apposing metal stent placement. The lesion was identified, and hemostasis was achieved with epinephrine injection and over-the-scope clip deployment. The patient made a full recovery with a healed lesion at outpatient follow-up. This method can pave the way for future improvement in minimally invasive treatment modalities for patients with altered gastrointestinal anatomy.

INTRODUCTION

Gastric remnant bleeding is a rare complication of Roux-en-Y Gastric Bypass (RYGB). It is hypothesized that the altered pathophysiologic environment of excluded anatomy and bile reflux can result in gastritis and peptic ulcer disease.¹ Endoscopic evaluation and treatment of upper gastrointestinal (GI) bleeding in patients with RYGB anatomy can be challenging. Conventional endoscopic techniques to access the remnant include single balloon enteroscopy and laparoscopic-assisted endoscopy.² Endoscopic ultrasound (EUS)-directed transgastric intervention (EDGI) is a newer endoscopic option which utilizes a lumen-apposing metal stent (LAMS) to facilitate access into the gastric remnant.^3,4 We present a case of acute GI bleeding in the duodenum after RYGB that is managed with an over-the-scope clip (OTSC) placed during a single-session EDGI.

CASE REPORT

A 72-year-old woman with a history of RYGB and breast cancer status post-double mastectomy with neoadjuvant chemotherapy on lifelong ado-trastuzumab emtansine presented with abdominal pain and melena. Her initial upper endoscopy revealed a marginal ulcer at the gastrojejunal anastomosis (Figure 1) without high-risk stigmata. She was discharged in stable condition but returned 2 days later with ongoing melena and worsening anemia. The patient's condition rapidly deteriorated, and she was admitted to the medical intensive care unit for hemorrhagic shock. Push enteroscopy showed bright red blood at the jejuno-jejunostomy, extending into the biliopancreatic limb (Figure 1). Single balloon enteroscopy under fluoroscopic guidance did not identify etiology for bleeding in the biliopancreatic limb, although the gastric remnant was not reached. A computed tomography angiography revealed contrast extravasation in the duodenal bulb (Figure 1). Interventional radiology was unable to identify a bleeding source on angiography. The patient continued to have active bleeding, requiring multiple blood transfusions. Following a multidisciplinary discussion, the decision was made to pursue EDGI. The remnant stomach was located under EUS, instilled with saline, contrast, and methylene blue, and a 10 × 20 mm electrocautery-enhanced LAMS was placed to create a gastrogastrostomy (Figure 1). The stent was secured with 2 endoscopic sutures and dilated to allow passage of the endoscope (Figure 1). A 15 mm Forrest IIa ulcer was found on the anterior wall of the duodenal bulb (Figure 1). Epinephrine was injected, and an OTSC was deployed over the ulcer (Figure 1). The patient's condition improved, and she was discharged in stable condition without evidence of rebleeding. Repeat upper endoscopy approximately 8 weeks later showed a healed duodenal ulcer with migration of the clip (Figure 1). The LAMS was removed, and argon plasma coagulation was applied to close the fistula.

Figure 1.

(A) 4 cm clean based gastric ulcer at the gastrojejunal anastomosis, (B) bright red blood and clot at the J-J anastomosis, (C) CT abdomen and pelvis with and without contrast showing a focus of contrast extravasation in the lumen of the second portion of the duodenum, which expands slightly on delayed imaging, (D) EUS-guided electrocautery-enhanced 10 × 20 mm LAMS deployment, (E) 2T endoscope overstitch system used for placement of 2 sutures, (F) a 15 mm duodenum bulb ulcer with a large visible vessel (Forrest IIa) on the anterior wall, (G) healed duodenal ulcer with migration of the clip, and (H) an over-the-scope clip deployed over the ulcer with 2.5 mL of epinephrine injected in 4 quadrants. CT, computed tomography; EUS, endoscopic ultrasound; LAMS, lumen-apposing metal stent.

DISCUSSION

EUS-guided interventions (EDGI) have been increasing in the past decade for a plethora of indications, such as management of varices, arterial bleeding, and portosystemic pressure gradient measurements.⁵ In particular, EDGI is a safe and effective procedure that has been developing as the preferred approach to enable access to the gastric remnant in patients with altered anatomy at centers with LAMS expertise. It provides the ability to perform endoscopic interventions with higher technical success and fewer complications compared with traditional methods.^3,4 This case highlights a minimally invasive approach to immediate diagnosis and management of massive upper GI bleeding in a patient with RYGB anatomy through a single-session EDGI procedure after negative catheter angiography along with the use of an OTSC for hemostasis. It also demonstrates the innovative use of EUS-guided direct access to a gastric remnant combined with OTSC placement in a single session—further highlighting a novel approach in management complex upper GI bleeding in patients with altered GI anatomy. Using EDGI to access the remnant allows for immediate diagnosis and intervention after a negative angiography, streamlining the treatment process. The integration of remnant access with OTSC deployment in one session offers effective hemostasis and the benefit for repeat interventions should rebleeding occur. Further improvements in strategies and methods with this technique may reduce risks and improve outcomes.

DISCLOSURES

Author contributions: SJ Pak: primary author; JE Basso: assisted with abstract and manuscript drafting; JC Edelson: attending physician on case and assured high quality of case report; SJ Pak is the article guarantor.

Financial disclosure: None to report.

Previous presentation: Abstract previously presented at ACG Annual Scientific Meeting; October 28, 2024; Philadelphia, Pennsylvania.

Informed consent was obtained for this case report.

ABBREVIATIONS:

APC

argon plasma coagulation

EDGI

endoscopic ultrasound-directed transgastric intervention

EUS

endoscopic ultrasound

GI

gastrointestinal

GJ

gastrojejunal

LAMS

lumen-apposing metal stent

OTSC

over-the-scope clip

RYGB

Roux-en-Y Gastric Bypass