GJ stricture & ulcer 3 years p/o roux en y

Question
After losing 25 lbs and put back on tpn, I was diagnosed with gastritis of the
native stomach and put on ibuprophen. I then developed severe substernal
pain and vomiting with eating, and was told it was due to the ibuprophen.  
After 6 weeks of this, an endoscopy revealed a GJ ulcer and stricture.  Since it
seems to be unusual at 3 yr p/o, and there is no agreement on the cause(s),
what is my best approach to prevent a recurrence?  Long term PPIs is all I can
find as a remedy after I stop the carafate.  And my symptoms were textbook
except for the 3 yr time period.  I think this bariatric surgeon should have
checked this out immediately before prescribing ibuprophen, or immediately
after the new symptoms appeared, which severely worsened the problem.  I
think he is an idiot.  Thanks for suggesting any preventative measures I
should try.  Dale

Answer
Dale,
Please let me summarize the situation to see if I have it right:

-gastric bypass about 3 years ago

-bowel obstruction (maybe an internal hernia?) after gastric bypass.  Not clear when this happened.

-large segment of small intestine removed as a result of the bowel obstruction.  Little enough small intestine is left to cause problems with nutrient absorption, and I would guess you also have frequent foul bowel movements.

-you were on TPN for some months, and gradually off TPN with lots of active work to modify and adjust your diet in the setting of the short intestine.

-you had pain and/or nausea, leading to the diagnosis of gastritis.  You lost ground on your weight and nutrition.

-you were treated with ibuprofen, and the situation got worse instead of better

-now back on TPN, still unable to eat, an upper scope has been done which showed the ulcer and stricture


I'm going to base my recommendations on the "facts" as I've outlined them above.  Please correct me if I am wrong on any pertinent points.

About ibuprofen and related meds - unfortunately the whole class of aspirin-related medications is fairly likely to cause ulcers in gastric bypass patients.  You have probably gathered at this point that you should never take aspirin, ibuprofen, or any medication in this class.  The only pain med that you can buy over the counter that is OK is Tylenol.  Prescription meds can also be OK, but most of them have their own set of side effects.

Short term management of eating intolerance - TPN for nutrition and PPI's to assist healing are the main things to do.  The scar that is causing the stricture is probably related to the inflammation from the active ulcer.  As the ulcer heals this stricture may soften and open up on its own, or it may me amenable to dilation by means of another scope.  If the stricture cannot be dilated, surgical revision may be necessary.

Big picture, and longer term management - I don't know enough to comment on the overall management by your surgeon, but my reading is that you have lost faith in him/her.  A solid physician/patient relationship is really important in a difficult long-term situation like yours, so I recommend you seek another experienced bariatric surgeon in your area.  The best avenue would be for you to look for a Center of Excellence surgeon in your area and then ask your first surgeon if he/she will facilitate a transfer of care.  This may be too difficult to approach interpersonally, so you could be forgiven for making a direct call to the potential new surgeon - the problem with this approach is that the new surgeon is likely to be somewhat resistant to taking over your care in "mid-stream."

Best of luck,
Dr JP

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