The price of surgery for weight reduction – gastrointestinal bleeding of unknown origin

We report the case of a 52 years old man who had diabetes mellitus, hypertension, hypothyroidism, depression and severe obesity in his history. In 2001 he underwent a successful surgical approach for severe obesity abroad. The details of the performed operation were unknown at the time of our examinations. Since 2004 sideropenic anemia was recognized, but no further examinations were performed. In 2006 acute, severe gastrointestinal bleeding occurred. Gastroscopy and colonoscopy could not reveal the source of the bleeding. During jejunoscopy an entero-enteral anastomosis could be seen. A lesion of the anastomosis was suggested as the cause of the bleeding. Urgent reconstruction of the anastomosis was performed. For the prevention of postoperative pulmonary embolism oral anticoagulant treatment was introduced. Despite the surgical approach the bleeding could not be stopped, the patient was admitted to our ward for further investigations. There was a huge discrepancy between the amount of transfusions needed by the patient and his slightly positive fecal blood test. Neither melena nor hematochesia could be seen. Repeated gastroscopy, colonoscopy, jejunoscopy and abdominal ultrasound could not identify the source of the bleeding. Tc-labelled red blood cell scintigraphy was performed which proved acute bleeding in the region of the duodenum. Abdominal CT showed a thickening of the wall of the duodenum. The patient underwent laparotomy, which revealed an anatomy identical to an atypical Roux-en-Y gastric bypass surgery with a nearly 1 meter long, blind small bowel segment. The cause of the bleeding was a chronic ulceration of the blind stomach wall invaginated into the duodenum. Malignancy could not be proven by histological evaluation. Antrum resection was performed. No further bleeding was recognized inspite of continuous anticoagulant treatment.