Originally published on Obesity.com

Think of an ulcer as a sore in the lining of your stomach. They can cause pain, bleeding or make a hole in the stomach called a perforation.  They can develop within a few months or even years out from surgery.

It is important for bariatric patients to know what are the causes and symptoms of gastric ulcers, when to contact their surgeon and how to prevent them from happening.

Causes of Ulcers After WLS

Some causes of ulcers after WLS are preventable and others are beyond our control.  The most common causes are smoking and NSAIDs.  NSAIDs – also known as non-steroidal anti-inflammatories – Ibuprofen, Naproxen, Motrin or Aleve.  Drinking alcohol and taking steroids such as Prednisone can also be the culprit.

Smoking can affect the lining of the stomach by reducing the amount of oxygen that gets to the tissues causing damage.  It can also impair wound healing.

NSAIDs can damage the lining of the stomach leading to gastritis (inflammation inside of  your stomach) or an ulcer.  Steroids may also affect the lining of the stomach and can delay healing.  If you require NSAIDs or oral steroids for certain conditions, please check with your surgeon first.

Alcohol is something to be cautious of after surgery.  Not only can you absorb alcohol much quicker, but it also irritates your pouch.  Imagine pouring rubbing alcohol on an open wound; this is the sort of effect that drinking alcohol has on your stomach.

Lastly, caffeine has not been shown to be a direct cause of ulcers; however it can act as an irritant. If you already have gastritis or inflammation inside your stomach, caffeine can make it worse.

Gastrogastric Fistula and Helicobacter Pylori

Factors out of our control leading to an ulcer include a large gastric pouch, gastrogastric fistula, Helicobacter pylori, and sutures used to close the pouch. It is thought that a large pouch produces too much acid which can lead to an ulcer.

Gastrogastric fistula is a complication in gastric bypass patients that connects the pouch to the bypassed stomach.  This connection is not normal and may allow acid to travel from your bypassed stomach to the small pouch and cause irritation.

Helicobacter pylori, often called H. pylori is a bacteria that could live in your stomach.  H. pylori can be contracted by saliva and body fluids of infected people.  This bacteria has been shown to cause gastritis or inflammation of the stomach lining.

Sutures may irritate the stomach and cause inflammation.

Symptoms of Ulcers

Patients with ulcers may experience abdominal pain, nausea, or vomiting.  Abdominal pain could be worse with eating or drinking.  If the ulcer is bleeding, the patient may have blood in the stool or dark tarry stools.

On occasion, patients ignore these symptoms or think that they are normal after surgery.  Remember, nausea, vomiting or abdominal pain is not normal after bariatric surgery, and you need to let your surgeon know about it.

After speaking with your surgeon’s office about your symptoms, you may be scheduled for an upper endoscopy. An upper endoscopy is a test where a small camera goes from your mouth to your pouch to investigate a cause for your symptoms.  This procedure is done while you are sedated.  A biopsy may be performed during this test to assess the tissue of the stomach.

Treatments

If an ulcer is found, your doctor may prescribe a proton-pump inhibitor (anti-acid medication) that you could remain on for an extended period of time.  Other medication might include Carafate.  It coats the lining of the stomach to aid in healing and protecting it from acid.  When ulcers are caused by NSAIDs, a medication called Cytoctec could be used.

While the ulcer is healing, you want to avoid caffeine because it can irritate the pouch and delay healing.  Your doctor may repeat the endoscopy to ensure that the ulcer has healed.

The worst case scenario of an untreated ulcer is bleeding or perforation of the stomach. Ulcers can erode (eat into) a blood vessel causing bleeding.  If that happens, you will likely be admitted to the hospital and started on medications.  If the bleeding does not stop with medications, you may need an endoscopy and/or surgery.  If you have lost a lot of blood, you may require a blood transfusion.

When there is a perforation (hole in your stomach) the contents of your stomach leak into the abdomen which can lead to a serious infection, sometimes causing peritonitis or sepsis.  In this situation, you may require emergency surgery.  Bleeding or perforation can be life-threatening.

Now you know that smoking, alcohol and NSAIDs are major risk factors for ulcers.  These preventable behaviors have the potential to create not only serious complications but life threatening situations. By knowing and understanding these factors, you can avoid future problems and live a healthy life after surgery.

Surgical photos courtesy of Dr. Dmitri Baranov

References

• Fringeli Y, Worreth M, Langer I. Gastrojejunal Anastomosis Complications and Their Management after Laparoscopic Roux-en-Y Gastric Bypass. Journal of Obesity. 2015;2015:698425. doi:10.1155/2015/698425.
• PALERMO M, ACQUAFRESCA PA, ROGULA T, DUZA GE, SERRA E. Late surgical complications after gastric by-pass: a literature review. Arquivos Brasileiros de Cirurgia Digestiva?: ABCD = Brazilian Archives of Digestive Surgery. 2015;28(2):139-143. doi:10.1590/S0102-67202015000200014.
• Ivanecz A, Sremec M, ?erani? D, Potr? S, Skok P. Life threatening bleeding from duodenal ulcer after Roux-en-Y gastric bypass: Case report and review of the literature. World Journal of Gastrointestinal Endoscopy. 2014;6(12):625-629. doi:10.4253/wjge.v6.i12.625

About the Author

Rachel Tierney is a Certified Physician Assistant. Rachel works for Saratoga Bariatric Surgery and Weight-Loss Program in Saratoga Springs, NY with Dr. Dmitri Baranov. Rachel assists Dr. Baranov in the operating room and sees patients in the inpatient and outpatient setting. She has been in the field of bariatric surgery and taking care of WLS patients since 2010. Rachel is a member of the American Society for Metabolic and Bariatric Surgery (ASMBS), and the American Academy of Physician Assistants (AAPA).