A 57-year-old man presented to the emergency department complaining of weakness, light-headedness, and melena. On admission, the patient was hypotensive (blood pressure, 84/44 mm Hg), tachycardic (heart rate, 126 beats per minute), and tachypneic (respiratory rate, 34 breaths per minute). His medical history included chronic renal insufficiency, coronary artery disease, hypertension, micronodular cirrhosis, and peptic ulceration. The patient also had Roux-en-Y gastric bypass surgery 12 years prior. The patient was a nonsmoker and was not on nonsteroidal anti-inflammatory medications (NSAIDs). It was unknown whether he had a history of Helicobactor pylori infection.
Laboratory results revealed a hemoglobin level of 7.6 g/dL and no coagulopathy. Despite multiple blood transfusions—2 units of packed red blood cells administered the day of admission and the day after admission—the patient's anemia persisted. Peroral endoscopy exposed a typical postgastric bypass anatomy without a source of bleeding. Subsequent celiac angiography revealed active bleeding in the duodenal area, and Gelfilm embolization was performed. However, as a result of ongoing hemorrhage, a surgical exploration was undertaken. An intraoperative upper endoscopy was performed through an anterior gastrotomy (
Figure 1). A 1-cm bleeding ulcer was identified in the posterolateral wall of the duodenum (
Figure 2).
The patient was taken immediately to the operating room. The endoscopy was then performed directly through a hole made in the stomach. The endoscope was withdrawn, and an anterior transverse duodenotomy was performed. After the duodenal ulcer was oversewn with interrupted 3-0 silk sutures, the duodenotomy and gastrotomy were closed in two layers. The patient had an unremarkable recovery and was discharged 5 days postoperation with a lifelong prescription for a proton pump inhibitor.