Endoscopic Ultrasound-Guided Gastric Remnant Access for Massive Upper Gastrointestinal Bleeding in Roux-en-Y Anatomy

Sep 29, 2026

Uploaded by dhado

Case report describing a successful endoscopic ultrasound-directed transgastric intervention (EDGI) for massive upper gastrointestinal bleeding in an unstable patient with Roux-en-Y anatomy. The remnant stomach was located under endoscopic ultrasound, accessed via gastrogastrostomy created using a lumen-apposing metal stent, and the bleeding lesion was treated with epinephrine injection plus over-the-scope clip deployment. Follow-up showed full recovery with a healed lesion and supports future refinement of minimally invasive care for altered gastrointestinal anatomy.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages3

Reading Time8 min

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Introduction

Case Report

Presentation and initial evaluation

EDGI procedure and hemostasis

Discussion

ACG CASE REPORTS JOURNAL CASE REPORT | ENDOSCOPY Endoscopic Ultrasound-Guided Gastric Remnant Access for Massive Upper Gastrointestinal Bleeding in Roux-en-Y Anatomy Soyoun J. Pak, MD 1 , Jessica E. Basso, MD2 , and Jerome C. Edelson, MD2 1 Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, TX 2Department of Gastroenterology, Brooke Army Medical Center, Fort Sam Houston, TX ABSTRACT This case reports a novel and successful attempt at identifying and treating massive upper gastrointestinal bleeding in an unstable patient with Roux-en-Y anatomy via endoscopic ultrasound-directed transgastric intervention and over-the-scope clip placement. The remnant stomach was located under endoscopic ultrasound and accessed via gastrogastrostomy, which was created via lumen-apposing metal stent placement. The lesion was identiﬁed, and hemostasis was achieved with epinephrine injection and over-the-scope clip deployment. The patient made a full recovery with a healed lesion at outpatient follow-up. This method can pave the way for future improvement in minimally invasive treatment modalities for patients with altered gastrointestinal anatomy. KEYWORDS: bariatric surgery;Roux-en-Y gastric bypass; upper gastrointestinal bleed;gastrointestinal bleeding; endoscopic ultrasound; EUSguided procedure; over-the-scope clip; lumen-apposing metal stent; LAMs; OTSC; advanced endoscopy ABBREVIATIONS: APC, argon plasma coagulation; EDGI, endoscopic ultrasound-directed transgastric intervention; EUS, endoscopic ultrasound; GI, gastrointestinal; GJ, gastrojejunal; LAMS, lumen-apposing metal stent; OTSC, over-the-scope clip; RYGB, Roux-en-Y Gastric Bypass INTRODUCTION Gastric remnant bleeding is a rare complication of Roux-en-Y Gastric Bypass (RYGB) . It is hypothesized that the altered pathophysiologic environment of excluded anatomy and bile reﬂux can result in gastritis and peptic ulcer disease.1 Endoscopic evaluation and treatment of upper gastrointestinal (GI) bleeding in patients with RYGB anatomy can be challenging. Conventional endoscopic techniques to access the remnant include single balloon enteroscopy and laparoscopic-assisted endoscopy.2 Endoscopic ultrasound (EUS)-directed transgastric intervention (EDGI) is a newer endoscopic option which utilizes a lumen-apposing metal stent (LAMS) to facilitate access into the gastric remnant.3,4 We present a case of acute GI bleeding in the duodenum after RYGB that is managed with an over-the-scope clip (OTSC) placed during a single-session EDGI. CASE REPORT A 72-year-old woman with a history ofRYGB and breast cancer status post-double mastectomy with neoadjuvant chemotherapy on lifelong ado-trastuzumab emtansine presented with abdominal pain and melena. Her initial upper endoscopy revealed a marginal ulcer at the gastrojejunal anastomosis (Figure1) without high-risk stigmata. She was discharged in stable condition but returned 2 days later with ongoing melena and worsening anemia. The patient’s condition rapidly deteriorated, and she was admitted to the medical intensive care unit for hemorrhagic shock. Push enteroscopy showed bright red blood at the jejunojejunostomy, extending into the biliopancreatic limb (Figure 1). Single balloon enteroscopy under ﬂuoroscopic guidance did not identify etiology for bleeding in the biliopancreatic limb, although the gastric remnant was not reached. A computed tomography angiography revealed contrast extravasation in the duodenal bulb (Figure 1) . Interventional radiology was unable to identify ACG Case Rep J 2026;13:e01949 . doi:10 . 14309/crj.0000000000001949. Published online: January 5, 2026 Correspondence: Soyoun J. Pak, MD ([soyounjpak@gmail.com](soyounjpak@gmail.com)) . ACG Case Reports [Journal / Volume 13 acgcasereports.com 1](Journal / Volume 13 acgcasereports.com 1) Pak et al Ultrasound-Guided Gastric Remnant Access Figure 1.(A) 4 cm clean based gastric ulcer at the gastrojejunal anastomosis,(B) bright red blood

FAQs

What clinical problem does this case report address?

It addresses massive upper gastrointestinal bleeding in a patient with Roux-en-Y anatomy, managed in an unstable clinical setting.

How was the gastric remnant accessed during EDGI?

The remnant stomach was localized with endoscopic ultrasound and accessed by creating a gastrogastrostomy using a lumen-apposing metal stent.

What was used to achieve hemostasis at the bleeding lesion?

The lesion was treated with epinephrine injection and an over-the-scope clip placed over the ulcer.

Sep 29, 2026

Uploaded by dhado