History

Fact Explanation
Pain The characteristic symptom of a gastrojejunal ulcer is pain, one-half to one and one-half hours after eating, similar to or more severe than the original ulcer pain. The pain being located to the left of the mid-line in the epigastrium, at the location of the ulcer.The pain may often be relieved by food or alkalis but occasionally by neither.[1].
Vomiting Vomiting may occur when there is obstruction at the stoma. As in other types of ulcer there may be a great tendency to remission of symptoms and periodic recrudescence.[1].
Nausea Persistent nausea is a frequent symptom found in patients with gastrojejunal ulcer.[2].
Perforation The ulcer is usually on the line of anastomosis, but may occur in the jejunum within two to three centimeters of it, where it has a great tendency to perforate. It may involve only a small portion of the stoma or its entire lumen with very extensive inflammatory infiltration of the adjacent mesocolon. And, finally, it may partly or completely close the stoma or perforate in to the colon to form a gastrocolic fistula.Clinically, there are two types.Acute fulminating perforation of a jejunal ulcer close to the stoma with no premonitory symptoms or slowly infiltrating and perforating marginal ulcer with periodic exacerbation of symptoms.[1].
Bleeding It has a great tendency to bleed. Blood in the stool is never absent. Hemorrhages are often profuse. There is usually melena and tarry stools, but never hematemesis.[1].
Loss of appetite and loss of weight. Food usually aggravates the condition, with the result that appetite becomes less and weight is lost.[2].
Acid eructations Acid eructations is also a frequent symptom.[2].
Formation of gastrocolic fistula The ulcer can perforate in to the colon to form a gastrocolic fistula. A gastrocolic fistula may be suspected when there are foul eructations and fecal vomiting, with diarrhea.The stools showing undigested food. The X-ray may aid in the diagnosis by demonstrating a deformed or painful stoma or obstruction.[1].
References
  1. ESTES WL JR. Advanced Gastrojejunal Ulcer Ann Surg [online] 1932 Aug, 96(2):250-257 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1391723
  2. COLP R. SURGICAL PROBLEMS IN THE TREATMENT OF GASTROJEJUNAL ULCERATION Ann Surg [online] 1941 Oct, 114(4):543-569 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1385811

Examination

Fact Explanation
Tenderness There will be a tenderness at the location of the ulcer on palpation.[1]The physical examination rarely discloses anything definite except deep supra-umbilical tenderness slightly to the left of the median line.[2].
Rigidity Detect in acute perforation of gastrojejunal ulcer. On examination greatest tenderness and rigidity may be in the left lower quadrant of the abdomen. Because fluid which escape through perforation passed downward on the left vertebral column.[3].
References
  1. ESTES WL JR. Advanced Gastrojejunal Ulcer Ann Surg [online] 1932 Aug, 96(2):250-257 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1391723
  2. COLP R. SURGICAL PROBLEMS IN THE TREATMENT OF GASTROJEJUNAL ULCERATION Ann Surg [online] 1941 Oct, 114(4):543-569 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1385811
  3. TOLAND CG, THOMPSON HL. ACUTE PERFORATION OF GASTROJEJUNAL ULCER: REPORT OF TEN NEW CASES AND A REVIEW OF NINETY-THREE COLLECTED CASES Ann Surg [online] 1936 Nov, 104(5):827-852 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1390253

Differential Diagnoses

Fact Explanation
Peptic ulcer disease The most difficult but least important conditions to be differentiate is perforation of recurrent gastric or duodenal ulcer.[1]. Mechanisms of injury differ distinctly between duodenal and gastric ulcers. Duodenal ulcer is essentially an H. pylori-related disease and is caused mainly by an increase in acid and pepsin load, and gastric metaplasia in the duodenal cap.Gastric ulcer, at least in Western countries, is most commonly associated with NSAID ingestion, although H. pylori infection might also be present. Symptoms of peptic ulcer disease commonly include epigastric pain, postprandial pain and nocturnal pain, pain that can wake the patient from sleep, and pain relieved by food or antacids. Less-common features include anemia caused by gastrointestinal blood loss, weight loss attributed to a reduced appetite caused by fear of pain, and vomiting associated with a gastric ulcer or pyloric stenosis. Pain does not define an ulcer, however, and the absence of pain does not preclude the diagnosis, especially in the elderly, who can present with 'silent' ulcer complications. No specific symptom helps differentiate between H. pylori-associated or NSAID-associated ulcers, but a careful history can identify surreptitious NSAID users and an appropriate H. pylori test can detect infected individuals.[2].
GERD (Gastro esophageal reflux disease) Heartburn (tight, burning sensation radiating from the xiphoid process to the neck) and acid regurgitation are typical symptoms. Also present with dyspepsia.Symptoms are exacerbated by fatty foods, caffeine, and recumbent position.GERD can mimic or exacerbate other diseases. Hoarseness, chronic cough, dental erosions, and asthma exacerbation may all occur with or without typical symptoms of GERD.[3].
Hiatus hernia Hiatal hernia contributes to GERD in obese patients before and after gastric bypass. They present with symptoms of GERD and abdominal pain. The prevalence of hiatus hernia is increased in obesity, and this anatomic defect may be under recognized and under treated during primary gastric bypass. As with primary GERD, medical therapy provides relief in the majority of patients. Elective repair of hiatal hernia has been shown to provide relief of abdominal pain and other GERD symptoms. [4].
Anastomotic stenosis Anastomotic stenosis most often presents within three months of surgery with incidences ranging from 3-20%, most often between 5-10%. Stenosis is characterized by dysphagia and is not a common cause of pain per se, but may accompany ulcer disease, anastomotic leak, or other pouch pathologies that are associated with pain. Isolated stenosis is rarely a cause of significant abdominal pain and if pain is a dominant symptom, other pathology should be sought. Stenosis appears to be more common after circular stapled gastrojenunal anastomosis.[4],[5].
References
  1. TOLAND CG, THOMPSON HL. ACUTE PERFORATION OF GASTROJEJUNAL ULCER: REPORT OF TEN NEW CASES AND A REVIEW OF NINETY-THREE COLLECTED CASES Ann Surg [online] 1936 Nov, 104(5):827-852 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1390253
  2. YUAN YUHONG, PADOL IRENEUSZ T, HUNT RICHARD H. Peptic ulcer disease today. Nat Clin Pract Gastroenterol Hepatol [online] 2006 February, 3(2):80-89 [viewed 15 August 2014] Available from: doi:10.1038/ncpgasthep0393
  3. SCHWARTZ MD. Dyspepsia, peptic ulcer disease, and esophageal reflux disease West J Med [online] 2002 Mar, 176(2):98-103 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071675
  4. GREENSTEIN AJ, O’ROURKE RW. Abdominal Pain following Gastric Bypass: Suspects & Solutions Am J Surg [online] 2011 Jun, 201(6):819-827 [viewed 16 August 2014] Available from: doi:10.1016/j.amjsurg.2010.05.007
  5. ESTES WL JR. Advanced Gastrojejunal Ulcer Ann Surg [online] 1932 Aug, 96(2):250-257 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1391723

Investigations - for Diagnosis

Fact Explanation
Ingestion of a barium meal Roentgenographic studies following the ingestion of a barium meal are invaluable in confirming the clinical diagnosis. These may be of inestimable aid in planning a therapeutic course. Their interpretation, to be sure, often requires unusual skill. Tenderness in the region of an irregular stoma while the patient is being fluoroscoped, a dilated stomach with retention of barium,suggestive of hypomotility or obstruction, the presence of barium patches in the jejunum, indicative of ulcer pockets, a stenosis or irregularity of either the afferent or efferent loops are helpful in the establishment of a diagnosis.The passage of a barium meal directly from the stomach outlining the colon concretely establishes the presence of a gastrojejunocolic fistula.[1].
Gastroscopic examination Gastroscopic examination with the flexible Schindler instrument has proved of considerable value in many of the more obscure cases. Areas of either actual gastrojejunal ulceration or the presence of scarring about the stoma may be distinctly seen. In addition to this, the presence of either an acute or chronic gastritis may aid in differentiating the clinical picture.[1].
Fractional test meals Fractional test meals are of confirmatory value because in the majority of these patients who have a constitutional tendency to develop ulcers the total acidity and free hydrochloric acid are usually high. Gastrojejunal ulceration in the presence of an anacidity is almost unknown. A study of the blood plasma chlorides and the CO2 combining power are important.For occasionally a severe alkalosis may be present without clinical manifestations.[1].
References
  1. COLP R. SURGICAL PROBLEMS IN THE TREATMENT OF GASTROJEJUNAL ULCERATION Ann Surg [online] 1941 Oct, 114(4):543-569 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1385811

Investigations - Screening/Staging

Fact Explanation
Acid secretion study The Hollander insulin test is used in patients following vagotomy. Although the effect of hypoglycemia on gastric secretion must be considered in relation to all gastric secretory nerves, and is in no way a quantitative test.It was believed that repeated tests on each patient, performed in a standardized manner, would have some statistical importance.[1].
References
  1. KNOX WG, WEST JP. Vagus Section in the Treatment of Gastrojejunal Ulcer: A Reappraisal After Long Term Follow Up Ann Surg [online] 1959 Apr, 149(4):481-485 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1451018

Management - General Measures

Fact Explanation
Bed rest Most patients get benefits from bed rest. Because of long continued dietary restrictions,pain, loss of sleep, and worry, many of the patients exhibit malnutrition to a serious degree. The disability in some cases is complete, and these patients are greatly benefited by a few days in the hospital with bed rest and good diet.[1].
Bland diet and fluids Patients should receive a bland diet and fluids in sufficient quantity to overcome the dehydration. Such measures are particularly beneficial when recent hemorrhage, exacerbation of inflammatory products, or retention have occurred.Not only is the general condition of the patient improved, but the activity of the lesion itself and the inflammatory reaction associated with it are reduced.[1].
Morphine The recurrence of the epigastric pain often so severe in its radiation to the back that morphine is required for its alleviation.[3].
Cessation of smoking and excessive intake of alcohol Persistent hypertonic and hyperacid stomach, often from excessive smoking or use of alcohol is considered as an etiological factor for development of gastrojejunal ulcer. So they are advised to stop smoking and consumption of alcohol.[2].
Proton pump inhibitor (PPI) therapy Once a diagnosis has been made of a gastrojejunal ulcer following either a gastro-enterostomy or a partial gastrectomy, any of the accepted medical methods of ulcer therapy should be tried first.[3] Uncomplicated MU (marginal ulcer) is generally managed with high-dose proton pump inhibitor (PPI) therapy. Preventive low-dose PPI or H2-blocker therapy is a common practice following RYGB (Roux-Y gastric bypass).Triple therapy is usually started in case of H. pylori infection.[4].
Discontinuation of NSAID The risk of postoperative MU is also increased by factors such as H. pylori infection, nonsteroidal anti-inflammatory drugs (NSAID), anticoagulation, and smoking. So NSAIDS should be discontinued.[4]
Blood transfusion If hemorrhage is present as a complicating factor, treatment either by absolute gastric rest and blood transfusion are advised. In cases of a gastric or a high jejunal obstruction with alkalosis, daily lavages of the stomach and the parenteral administration of adequate amounts of saline, glucose, and blood are essential.[3].
Endoscopic management Hemodynamically significant upper GI bleed secondary to MU is managed endoscopically or surgically, after initiating intravenous formulations of proton pump inhibitor therapy. In some institutions, an 80-mg intravenous bolus of pantoprazole followed by an infusion at a rate of 8mg/hr is used. Endoscopic options include heater probe coaptive coagulation, bipolar probe coaptive coagulation, chemical sclerosant, epinephrine injection, laser therapy, and hemostatic clip placement.[4].
Vagotomy Patients who developed marginal ulceration after gastrectomy can be satisfactorily treat with vagotomy. but recurrence can be seen.[5].
Partial gastrectomy Usually the likelihood of gastrojejunal ulcer following gastroenterostomy for duodenal ulcer is considerably greater than following gastroenterostomy for gastric ulcer.In the case of an uncomplicated gastrojejunal ulcer partial gastrectomy can usually be conducted in a very precise manner.Each step in the operation should be completed before subsequent steps are undertaken. It is hardly necessary to say that one should make as complete an exploration of the abdomen as is possible. Although, when several operations have already been performed, detailed exploration involving extensive dissection is unwise because of the time consumed and the trauma inflicted.The symptomatic results following partial gastrectomy for gastrojejunal ulcer fully justify adhering to the principle that this operation is necessary in those cases which do not permit the conservative practice of disconnecting the anastomosis only. Complete relief of symptoms follows the operation in more than 85 per cent. [1].
Excision of ulcer and abolition of the stoma. Surgical procedure depends upon the type of lesion found.When the original duodenal ulcer is found to be healed and the marginal ulcer small, abolition of the stoma with excision of the ulcer is the most satisfactory operation. Rarely will simple excision of the ulcer suffice. When the duodenal ulcer is still present, abolition of the stoma with resection of the marginal ulcer should be supplemented by a pyloroplasty or gastric resection.[2]
References
  1. BALFOUR DC. THE OCCURRENCE AND MANAGEMENT OF GASTROJEJUNAL ULCER Ann Surg [online] 1926 Aug, 84(2):271-280 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1399233
  2. ESTES WL JR. Advanced Gastrojejunal Ulcer Ann Surg [online] 1932 Aug, 96(2):250-257 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1391723
  3. COLP R. SURGICAL PROBLEMS IN THE TREATMENT OF GASTROJEJUNAL ULCERATION Ann Surg [online] 1941 Oct, 114(4):543-569 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1385811
  4. SIDANI S, AKKARY E, BELL R. Catastrophic Bleeding From a Marginal Ulcer After Gastric Bypass JSLS [online] 2013, 17(1):148-151 [viewed 15 August 2014] Available from: doi:10.4293/108680812X13517013318274
  5. KNOX WG, WEST JP. Vagus Section in the Treatment of Gastrojejunal Ulcer: A Reappraisal After Long Term Follow Up Ann Surg [online] 1959 Apr, 149(4):481-485 [viewed 16 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1451018

Management - Specific Treatments

Fact Explanation
Feeding jejunostomy In advanced gastrojejunal ulcer, so-called "protected perforated" with wide inflammatory reaction in the mesentery of the colon, can use preliminary jejunostomy for feeding, to permit by rest of the ulcer area recession of the reaction and partial healing of the ulcer.So that a later resection may be more easily and safely undertaken.[1].
Roux or Y type of anastomosis For operation on an ulcer recurrent in the stoma following gastric resection and in repeated recurrent ulcer a Roux or Y type of anastomosis may offer the best solution.[1].
References
  1. ESTES WL JR. Advanced Gastrojejunal Ulcer Ann Surg [online] 1932 Aug, 96(2):250-257 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1391723