1. a-00025
Dr. Robert RUTLEDGE
Title of Paper: BILE, REFLUX, GASTRITIS AND MARGINAL
ULCER FOLLOWING BILLROTH II; MANAGEMENT OF
DYSPEPSIA AFTER MINI-GASTRIC BYPASS
Nationality: United States of America
Position: Director
Department: Surgery
Organization: Center For Laparoscopic Obesity Surgery
Tel: +1-702 714 0011

2. Marginal ulcer in jejunum after RNY. 3-cm ulcer (Long arrows)
in proximal jejunum abutting G-J anastomosis (Small arrow).
Narrow anastomosis, edema and spasm.
Marginal Ulcer &
Gastric Bypass

3. BILE, REFLUX, GASTRITIS AND
MARGINAL ULCER FOLLOWING
BILLROTH II; MANAGEMENT OF
DYSPEPSIA AFTER MINI-GASTRIC
BYPASS
Robert RUTLEDGE1
1Director, Surgery, Center For Laparoscopic
Obesity Surgery, United States of America

4. Epidemiology: What do we know
about Marginal Ulcers?
• “Marginal ulcers represent one of the
most problematic postoperative
complications following Roux-en-Y”
• Reported “incidence of marginal ulcers
is 0.6 to 16 %” in RNY Bypass

5. As Old as
Abdominal Gastric Surgery
• MARGINAL, GASTROJEJUNAL OR
PEPTIC ULCER SUBSEQUENT TO
GASTROENTEROSTOMY.
• Erdmann JF.
• Ann Surg. 1921 Apr;73(4):434-40

6. Marginal Ulcer in RNY Gastric Bypass
• 2,282 RNY Gastric Bypass
• 122 (5%) Marginal ulcers
• 39 (32%) Surgery
• Surg Obes Relat Dis. 2009 May-Jun;5(3):317-22. Revisional
operations for marginal ulcer after Roux-en-Y gastric bypass. Patel
RA, Brolin RE, Department of Surgery, University Medical Center at
Princeton, Princeton, New Jersey 08536

7. Introduction
• Dyspepsia post Mini-Gastric Bypass
(MGB, Billroth II gastro-jejunostomy) may
be
• Erroneously labeled as "bile reflux."
• Thousands of Billroth II (BII) patients have
bile that flows harmlessly across their BII
anastomosis every day.
• In 6253 MGB patients, bile routinely flows
across their BII with No symptoms.

8. Introduction
• All patients with a Gastro-jejunostomy
(GJ) have a well described risk of a
variety of GI symptoms (i.e.: burning,
nausea, vomiting, etc.)
• For over 100 yrs General Surgeons
have known that all forms of G-J
anastomoses can develop Marginal
Ulcer

9. Marginal Ulcer has been known since the
beginning GI Surgery
 THE ROENTGEN DIAGNOSIS AND LOCALIZATION
OF MARGINAL PEPTIC ULCER.
 Carman RD.
 Cal State J Med. 1920 Nov;18(11):377-82

10. Marginal Ulcer has been known since the
beginning GI Surgery
 Re-evaluation of the role of the pyloric antrum in
marginal peptic ulcers.
 SCHILLING JA, PEARSE HE.
 Surg Gynecol Obstet. 1948 Aug;87(2):225-34

11. Marginal Ulcer has been known since the
beginning GI Surgery
 Vagotomy as a treatment for marginal ulcer.
 CRILE G Jr, BROWN GM Jr.
 Gastroenterology. 1951 Jan;17(1):14-9

12. Marginal Ulcer has been known since the
beginning GI Surgery
 Review Article: The present status of the
management of marginal ulcer.
 BYRD BF Jr.
 J Tn State Med Assoc. 1953 Feb;46(2):56-8.

13. Marginal Ulcer has been known since the
beginning GI Surgery
 2,282 RYGB
 122 (5%) Marginal ulcers
 39 (32%) Surgery
 Surg Obes Relat Dis. 2009 May-Jun;5(3):317-22. Revisional operations for marginal
ulcer after Roux-en-Y gastric bypass. Patel RA, Brolin RE, Department of
Surgery, University Medical Center at Princeton, Princeton, New Jersey 08536

14. Marginal Ulcer Very High After
RNY Gastric Bypass
 441 RYGB
 10 (12%) of RNY gastric bypass presented an "early"
marginal ulcer
 Asymptomatic (28%)
 Obes Surg. 2009 Feb;19(2):135 Incidence of marginal ulcer 1 month and 1 to 2 years
after gastric bypass: a prospective consecutive endoscopic evaluation of 442 patients
with morbid obesity. Csendes A et al Department of Surgery, University
Hospital, University of Chile, Santiago, Chile.

15. Dyspepsia after MGB
• While it is possible that these patients
can develop "bile reflux, "
• The usual etiology of dyspepsia
following BII
• IS NOT BILE
• but the more common of acid peptic
disease (gastritis/ulcer.)

16. Think Three Pieces of Evidence
• Marginal Ulcer in 100 years of G-J (BII
and RNY)
• Marginal Ulcer in RNY Gastric Bypass
(No Bile)
• Marginal Ulcer in MGB
(+Bile)

17. Marginal Ulcer Rates
• Marginal Ulcer in 100 years of G-J (BII
and RNY)
• (5%)
• Marginal Ulcer in RNY Gastric Bypass
(No Bile)
• (5%)
• Marginal Ulcer in MGB
(+Bile)
• (5%)

18. Results
• Management Protocol: MGB patients
suffering from dyspepsia symptoms,
(symptoms that might easily be called
"bile reflux")

19. Results
• History:
?Daily Yogurt (protective);
Alcohol/processed meats/"junk foods, "
NSAIDS, Smoking (“Ulcerogenic”), Labs: H.
Pylori, Hgb Fe LFT, s etc.
• Recommend:
Yogurt (plain) daily + probiotics,
AVOID: alcohol, cigarettes, tobacco, NSAIDs

20. Results
• Medical treatment:
• Rx H. Pylori,
• PPI's/H2 Blockers,
• +/- Carafate/Bismuth, other antacid
treatment
• Note: Never anti-Bile Rx

21. Results
• In 6253 patients,
• Followed for 15 years,
• Dyspepsia (5%)
• Medical treatment was effective in all
but
• 3 patients
(Rx Braun Side to side Jejuno-
jejunostomy (J-J).

22. Conclusions
• The rising adoption of the MGB may
lead to confusion when surgeons are
faced with post operative BII patients.
• Dyspepsia is relatively common after
gastro-jejunostomy (BII = RNY).

23. Conclusions
• In the vast majority of these cases the
etiology is common acid peptic disease
causing marginal gastritis/ulcer and is
routinely responsive to medical
treatment.
• Failure of medical treatment is rare, but
easily managed by brief laparoscopic
Braun side to side J-J.

24. Confusion
• Bile
• Bile Reflux
• Bile reflux Gastritis
• Marginal Ulcer

25. Confusion
• Bile; Everyone has Bile
• Bile Reflux; BII has More Bile Reflux than
others
• Bile reflux Gastritis; Endoscopy of
symptomatic Pts shows some gastritis in
some patients (as in RNY pts)
• Marginal Ulcer; Equal in RNY & MGB
• Bile Makes No Difference