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Unraveling a patient’s post-op symptoms
The correct answer is B: endoscopic suture removal. As the prevalence of bariatric surgery increases to address the obesity epidemic, endoscopists are increasingly called upon to evaluate postbariatric patients.1 In one case series of patients undergoing EGD for upper GI symptoms post-RYGB, normal postsurgical anatomy was found in 31.6%, anastomotic stricture in 52.6%, marginal ulcer in 15.8%, unraveled suture material causing functional obstruction in 4% and gastro-gastric fistula in 2.6% of cases.2 Another series reported unraveled suture material thought to be contributing to upper GI symptoms in up to 10% of cases.3 Suture material is found by a mean of 34 weeks after RYGB, and presenting symptoms include abdominal pain in 65%, nausea 52%, dysphagia 22%, and melena in 13%. Unraveled suture material may be associated with marginal ulceration, or may cause obstruction as it presents a mechanical obstruction to foodstuff as it passes through the gastrojejunal anastomosis. A series of 29 therapeutic endoscopic suture removal cases reported resolution or improvement of symptoms in 83% of patients and no complications or anastomotic leaks.3
While symptomatic management with antiemetics and analgesics (answer A) is important in managing this patient, it will not lead to definitive management of her underlying condition. The patient may require laparosopic surgical revision (answer C) if her symptoms persist after endoscopic suture removal, but it is premature to recommend this. An upper GI series (answer D) would be helpful in diagnosing a gastro-gastric fistula in this patient population, but the endoscopic evaluation suggests suture material leading to food bolus impaction and gut irritation is the cause of her symptoms. Finally, while the patient’s symptoms of intermittent obstruction raises concerns for gastrojejunal stenosis, the endoscopic exam showed a normal-caliber stoma. Thus, stomal dilation (answer E) is incorrect.
References
1. ASGE Standards of Practice Committee, Evans J.A., Muthusamy V.R., et al. The role of endoscopy in the bariatric surgery patient. Gastrointest Endosc. 2015;8:1063-72.
2. Lee J.K., Van Dam J., Morton J.M., et al. Endoscopy is accurate, safe, and effective in the assessment and management of complications following gastric bypass surgery. Am J Gastroenterol. 2009;104:575-82.
3. Yu S., Jastrow K., Clapp B., et al. Foreign material erosion after laparoscopic Roux-en-Y gastric bypass: findings and treatment. Surg Endosc. 2007;21:1216-20.
The correct answer is B: endoscopic suture removal. As the prevalence of bariatric surgery increases to address the obesity epidemic, endoscopists are increasingly called upon to evaluate postbariatric patients.1 In one case series of patients undergoing EGD for upper GI symptoms post-RYGB, normal postsurgical anatomy was found in 31.6%, anastomotic stricture in 52.6%, marginal ulcer in 15.8%, unraveled suture material causing functional obstruction in 4% and gastro-gastric fistula in 2.6% of cases.2 Another series reported unraveled suture material thought to be contributing to upper GI symptoms in up to 10% of cases.3 Suture material is found by a mean of 34 weeks after RYGB, and presenting symptoms include abdominal pain in 65%, nausea 52%, dysphagia 22%, and melena in 13%. Unraveled suture material may be associated with marginal ulceration, or may cause obstruction as it presents a mechanical obstruction to foodstuff as it passes through the gastrojejunal anastomosis. A series of 29 therapeutic endoscopic suture removal cases reported resolution or improvement of symptoms in 83% of patients and no complications or anastomotic leaks.3
While symptomatic management with antiemetics and analgesics (answer A) is important in managing this patient, it will not lead to definitive management of her underlying condition. The patient may require laparosopic surgical revision (answer C) if her symptoms persist after endoscopic suture removal, but it is premature to recommend this. An upper GI series (answer D) would be helpful in diagnosing a gastro-gastric fistula in this patient population, but the endoscopic evaluation suggests suture material leading to food bolus impaction and gut irritation is the cause of her symptoms. Finally, while the patient’s symptoms of intermittent obstruction raises concerns for gastrojejunal stenosis, the endoscopic exam showed a normal-caliber stoma. Thus, stomal dilation (answer E) is incorrect.
References
1. ASGE Standards of Practice Committee, Evans J.A., Muthusamy V.R., et al. The role of endoscopy in the bariatric surgery patient. Gastrointest Endosc. 2015;8:1063-72.
2. Lee J.K., Van Dam J., Morton J.M., et al. Endoscopy is accurate, safe, and effective in the assessment and management of complications following gastric bypass surgery. Am J Gastroenterol. 2009;104:575-82.
3. Yu S., Jastrow K., Clapp B., et al. Foreign material erosion after laparoscopic Roux-en-Y gastric bypass: findings and treatment. Surg Endosc. 2007;21:1216-20.
The correct answer is B: endoscopic suture removal. As the prevalence of bariatric surgery increases to address the obesity epidemic, endoscopists are increasingly called upon to evaluate postbariatric patients.1 In one case series of patients undergoing EGD for upper GI symptoms post-RYGB, normal postsurgical anatomy was found in 31.6%, anastomotic stricture in 52.6%, marginal ulcer in 15.8%, unraveled suture material causing functional obstruction in 4% and gastro-gastric fistula in 2.6% of cases.2 Another series reported unraveled suture material thought to be contributing to upper GI symptoms in up to 10% of cases.3 Suture material is found by a mean of 34 weeks after RYGB, and presenting symptoms include abdominal pain in 65%, nausea 52%, dysphagia 22%, and melena in 13%. Unraveled suture material may be associated with marginal ulceration, or may cause obstruction as it presents a mechanical obstruction to foodstuff as it passes through the gastrojejunal anastomosis. A series of 29 therapeutic endoscopic suture removal cases reported resolution or improvement of symptoms in 83% of patients and no complications or anastomotic leaks.3
While symptomatic management with antiemetics and analgesics (answer A) is important in managing this patient, it will not lead to definitive management of her underlying condition. The patient may require laparosopic surgical revision (answer C) if her symptoms persist after endoscopic suture removal, but it is premature to recommend this. An upper GI series (answer D) would be helpful in diagnosing a gastro-gastric fistula in this patient population, but the endoscopic evaluation suggests suture material leading to food bolus impaction and gut irritation is the cause of her symptoms. Finally, while the patient’s symptoms of intermittent obstruction raises concerns for gastrojejunal stenosis, the endoscopic exam showed a normal-caliber stoma. Thus, stomal dilation (answer E) is incorrect.
References
1. ASGE Standards of Practice Committee, Evans J.A., Muthusamy V.R., et al. The role of endoscopy in the bariatric surgery patient. Gastrointest Endosc. 2015;8:1063-72.
2. Lee J.K., Van Dam J., Morton J.M., et al. Endoscopy is accurate, safe, and effective in the assessment and management of complications following gastric bypass surgery. Am J Gastroenterol. 2009;104:575-82.
3. Yu S., Jastrow K., Clapp B., et al. Foreign material erosion after laparoscopic Roux-en-Y gastric bypass: findings and treatment. Surg Endosc. 2007;21:1216-20.
Published previously in Gastroenterology (2016;151:250-1)
A 45-year-old female with history of morbid obesity who had undergone Roux-en-Y gastric bypass (RYGB) 6 months ago for weight loss presents to the emergency department with acute on chronic abdominal pain. She reports that these upper gastrointestinal symptoms have been occurring with increasing frequency over the past 2 months. Her pain is epigastric, postprandial, and without radiation. 
Dr. Storm and Dr. Thompson are in the department of medicine, division of gastroenterology, hepatology and endoscopy, Brigham and Women’s Hospital, Boston. Dr. Thompson is a consultant for Olympus, Cook, and Boston Scientific.
Junior Investigators are Top Priority for Gastroenterology Editors
In a recent video interview, Richard Peek Jr., MD, AGAF, Editor in Chief, and Douglas Corley, MD, PhD, Deputy Editor in Chief, of Gastroenterology explained how trainees and young GIs fit into their plans for the journal. Good news: this constituency is among the editors’ top priorities.
The editors have plans to implement a year-long editorial fellowship later in their term, which will allow an individual to get hands-on experience in the editorial process.
The editors also appreciate the fresh take young investigators have on research. To encourage continued high-quality submissions from young investigators, the editors will decrease submission fees for young investigators and work to increase the visibility of young investigator research.
The editors also plan to develop new features within the Gastroenterology Mentor, Education and Training Corner that will be of interest to trainees and early career GIs.
Watch the full video interview on AGA’s YouTube Channel: https://www.youtube.com/user/AmerGastroAssn.
The discussion on young investigators begins at minute 5:24.
In a recent video interview, Richard Peek Jr., MD, AGAF, Editor in Chief, and Douglas Corley, MD, PhD, Deputy Editor in Chief, of Gastroenterology explained how trainees and young GIs fit into their plans for the journal. Good news: this constituency is among the editors’ top priorities.
The editors have plans to implement a year-long editorial fellowship later in their term, which will allow an individual to get hands-on experience in the editorial process.
The editors also appreciate the fresh take young investigators have on research. To encourage continued high-quality submissions from young investigators, the editors will decrease submission fees for young investigators and work to increase the visibility of young investigator research.
The editors also plan to develop new features within the Gastroenterology Mentor, Education and Training Corner that will be of interest to trainees and early career GIs.
Watch the full video interview on AGA’s YouTube Channel: https://www.youtube.com/user/AmerGastroAssn.
The discussion on young investigators begins at minute 5:24.
In a recent video interview, Richard Peek Jr., MD, AGAF, Editor in Chief, and Douglas Corley, MD, PhD, Deputy Editor in Chief, of Gastroenterology explained how trainees and young GIs fit into their plans for the journal. Good news: this constituency is among the editors’ top priorities.
The editors have plans to implement a year-long editorial fellowship later in their term, which will allow an individual to get hands-on experience in the editorial process.
The editors also appreciate the fresh take young investigators have on research. To encourage continued high-quality submissions from young investigators, the editors will decrease submission fees for young investigators and work to increase the visibility of young investigator research.
The editors also plan to develop new features within the Gastroenterology Mentor, Education and Training Corner that will be of interest to trainees and early career GIs.
Watch the full video interview on AGA’s YouTube Channel: https://www.youtube.com/user/AmerGastroAssn.
The discussion on young investigators begins at minute 5:24.
Acute pancreatitis
Dear Colleagues,
Acute pancreatitis has long been one of the “bread and butter” conditions in gastroenterology and having up-to-date knowledge on its management will serve our community well. In this issue of The New Gastroenterologist, Abhishek Gulati and Georgios Papachristou (University of Pittsburgh) provide a comprehensive review of the latest advances in the treatment of acute pancreatitis and its complications, which has direct application to GI clinical practice.
Also included in this issue of The New Gastroenterologist is an article highlighting the importance of diversity in gastroenterology training by Sandra Quezada (University of Maryland) and an article on financial tips to ensure a secure retirement by an experienced contract and tax attorney. Additionally, Peter Liang (New York University), Tatyana Kushner (University of California at San Francisco), and Folasade May (University of California at Los Angeles), who are all members of the AGA Institute Trainee and Early Career Committee, provide an overview of the work that they have done to benefit the early career gastroenterology community and the opportunities that exist for getting involved in related AGA activities.
In prior issues of The New Gastroenterologist, we have typically featured a case from the “Clinical Challenges and Images in GI” section of Gastroenterology. However, in this issue we will instead feature a “Practical Teaching Case,” which is one of Gastroenterology’s newest features with a specific focus on the trainee and early-career gastroenterologist. These new cases are great didactic resources and I hope that they become a part of the regular reading of the early career GI community.
If you enjoy the articles in The New Gastroenterologist, have suggestions for future issues, or are interested in contributing to future issues, please let us know! You can contact me ([email protected]) or the Managing Editor of The New Gastroenterologist, Ryan Farrell ([email protected]).
Sincerely,
Bryson W. Katona, MD, PhD
Editor in Chief
Bryson W. Katona is a instructor of medicine in the division of gasteroenterology at the University of Pennsylvania.
Dear Colleagues,
Acute pancreatitis has long been one of the “bread and butter” conditions in gastroenterology and having up-to-date knowledge on its management will serve our community well. In this issue of The New Gastroenterologist, Abhishek Gulati and Georgios Papachristou (University of Pittsburgh) provide a comprehensive review of the latest advances in the treatment of acute pancreatitis and its complications, which has direct application to GI clinical practice.
Also included in this issue of The New Gastroenterologist is an article highlighting the importance of diversity in gastroenterology training by Sandra Quezada (University of Maryland) and an article on financial tips to ensure a secure retirement by an experienced contract and tax attorney. Additionally, Peter Liang (New York University), Tatyana Kushner (University of California at San Francisco), and Folasade May (University of California at Los Angeles), who are all members of the AGA Institute Trainee and Early Career Committee, provide an overview of the work that they have done to benefit the early career gastroenterology community and the opportunities that exist for getting involved in related AGA activities.
In prior issues of The New Gastroenterologist, we have typically featured a case from the “Clinical Challenges and Images in GI” section of Gastroenterology. However, in this issue we will instead feature a “Practical Teaching Case,” which is one of Gastroenterology’s newest features with a specific focus on the trainee and early-career gastroenterologist. These new cases are great didactic resources and I hope that they become a part of the regular reading of the early career GI community.
If you enjoy the articles in The New Gastroenterologist, have suggestions for future issues, or are interested in contributing to future issues, please let us know! You can contact me ([email protected]) or the Managing Editor of The New Gastroenterologist, Ryan Farrell ([email protected]).
Sincerely,
Bryson W. Katona, MD, PhD
Editor in Chief
Bryson W. Katona is a instructor of medicine in the division of gasteroenterology at the University of Pennsylvania.
Dear Colleagues,
Acute pancreatitis has long been one of the “bread and butter” conditions in gastroenterology and having up-to-date knowledge on its management will serve our community well. In this issue of The New Gastroenterologist, Abhishek Gulati and Georgios Papachristou (University of Pittsburgh) provide a comprehensive review of the latest advances in the treatment of acute pancreatitis and its complications, which has direct application to GI clinical practice.
Also included in this issue of The New Gastroenterologist is an article highlighting the importance of diversity in gastroenterology training by Sandra Quezada (University of Maryland) and an article on financial tips to ensure a secure retirement by an experienced contract and tax attorney. Additionally, Peter Liang (New York University), Tatyana Kushner (University of California at San Francisco), and Folasade May (University of California at Los Angeles), who are all members of the AGA Institute Trainee and Early Career Committee, provide an overview of the work that they have done to benefit the early career gastroenterology community and the opportunities that exist for getting involved in related AGA activities.
In prior issues of The New Gastroenterologist, we have typically featured a case from the “Clinical Challenges and Images in GI” section of Gastroenterology. However, in this issue we will instead feature a “Practical Teaching Case,” which is one of Gastroenterology’s newest features with a specific focus on the trainee and early-career gastroenterologist. These new cases are great didactic resources and I hope that they become a part of the regular reading of the early career GI community.
If you enjoy the articles in The New Gastroenterologist, have suggestions for future issues, or are interested in contributing to future issues, please let us know! You can contact me ([email protected]) or the Managing Editor of The New Gastroenterologist, Ryan Farrell ([email protected]).
Sincerely,
Bryson W. Katona, MD, PhD
Editor in Chief
Bryson W. Katona is a instructor of medicine in the division of gasteroenterology at the University of Pennsylvania.