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Welcome back to another episode of Behind the Night with your bariatric team from the University of Nebraska Medical Center.

My name is Dr. Haskins and I am joined with Dr. McBride as well as Dr. Tanner.

And we thought that today we would talk about one of the more common cases that we see after bariatric surgery, which is a marginal ulcer.

And Dr. McBride is going to start us off with a bit of a case presentation.

Thank you.

So this is a patient that actually we saw about this time last year.

She's a long standing patient of mine. She's a 45 year old woman who was about two and a half years after her laparoscopic ruined why gastric bypass.

I had done her using a laparoscopic linear stapled technique.

My standard technique is a 30 purple load and then closing the common aneurotomy with an absorbable Veloc suture.

Prior to her gastric bypass, she'd had hypertension treated with Lycinopril and diabetes treated with metformin, but she was now completely off these medications.

She had been a one pack per day smoker, but she'd quit as part of the preoperative process.

She had kept all of her standard postoperative follow up and had been doing very well with the weight loss process.

However, at approximately this time last year in that week between Christmas and New Year's, she presented to the emergency department with new onset of a boring epigastric pain that she said radiated through to her back, but to nowhere else.

She was associated with some nausea that had been going on for about four to five days, occasional vomiting, but no hematemesis, but no other symptoms, no fever, chills, no change in her bowel habit.

She had been able to eat, but had noticed some decrease in her ability to drink and she felt like she was having difficulty maintaining her hydration.

The patient was a little more concentrated and she was concerned about dehydration, which was part of what brought her to the emergency department.

Correa, this sounds like a very typical case that we see for marginal ulcers.

When I first think, and I get this call either from the resident or the fellow from the emergency department, one of the first things I think of since this does sound like a very typical marginal ulcer is what are their risk factors.

So can you discuss for us some of those risk factors?

Absolutely. Well, certainly when I was called that week, the things I kind of asked about were because she was a former smoker had she returned to smoking and unfortunately in her case she had the stress of the holiday season had resulted in returns to a couple of the behaviors that we very actively discourage in our bariatric patients in general, but specifically in our gastric bypass patients.

A little before Thanksgiving, she had started smoking again and she was back up to a one pack per day smoker.

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