Surgeons' Confusion &Misunderstanding the MGB:Bile, Bile Reflux, Bile Reflux Gastritis, Acid Peptic Gastritis & Marginal Ulcer Following Billroth II / MGB; Correct Management of Dyspepsia

1. Bile Reflux, Gastritis, Ulcer,
Fainting/Salt,
Estrogen Depression
5:00pm to 5:50pm (010)

2. “Bile” & The MGB
But Before We Get Started

3. Fainting/Salt
In Short:
MGB => Massive Diuresis => Dehydration
Often Post Op Weakness Dizzy & Occasional Fainting Syncope
Rx Simple: Keep Salt Packets and bottled water near by at all times
Rapid Rehydration is curative in minutes
Post Op Diet/Medications
Stop/Hold/Cut Back BP Meds, Soups & Crackers
Test for Dehydration: Postural Hypotension

4. Estrogen & Depression
In Short:
Estrogen Decline Rapidly after MGB
(Rx Poly Cystic Ovary Disease)
Rapid Decline in Estrogen may often Lead to Depression
(Think Menopause)
Rx 1-6 month supplemental estrogen (patch >> pill)

5. Estrogen & MGB
Infertility & PCOD
In Short:
MGB Rx Poly Cystic Ovary Disease
Many Infertile Couples with Failed IVF
Successful Healthy Pregnacny After MGB
Beware: If You DO NOT Want another child you may get a
surprise from the MGB!

6. MGB Pregnancy
#1 Prevent Anemia (See Later Lecture)
Rutledge Study
324 Patients Pregnacy Before & After MGB
39% of Patient had Pregnancy Complication Pre MGB
7% Had Pregnancy Complication After MGB

7. Bile
Bile Reflux
Bile Reflux Gastritis
Misunderstanding and
Unnecessary Surgery

8. Dx & Rx
Bile Reflux Gastritis & the
Billroth II (Important!)
Confusion & Unnecessary Surgery

9. Surgeons' Confusion &
Misunderstanding the MGB:
Bile, Bile Reflux, Bile Reflux Gastritis,
Acid Peptic Gastritis & Marginal Ulcer
Following Billroth II / MGB;
Correct Management of Dyspepsia

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

11. Bile, Bile Reflux, Bile Reflux Gastritis,
Acid Peptic Gastritis & Marginal Ulcer
Following Billroth II / MGB;
Correct Management of Dyspepsia
Robert RUTLEDGE1
1Director, Surgery, Center For Laparoscopic Obesity
Surgery, United States of America

12. 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

13. Marginal Ulcer:
As Old as Abdominal Gastric Surgery
MARGINAL, GASTROJEJUNAL OR
PEPTIC ULCER SUBSEQUENT TO
GASTROENTEROSTOMY.
Erdmann JF.
Ann Surg. 1921 Apr;73(4):434-40
NOT New to the Mini-Gastric Bypass

14. Marginal Ulcer in RNY Gastric Bypass
2,282 RNY Gastric Bypass
122 (5%) Marginal ulcers
39 (32%) Surgery
Not Only the MGB
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

15. Introduction
For more than 20 years
in 6,253 MGB patients,
bile routinely flows across their BII
with
No symptoms

16. Introduction
Tens of Thousands of General
Surgery Billroth II patients from
all around the world have bile
that flows harmlessly across
their Billroth II anastomosis
every day, refluxing into the
stomach

17. Introduction
Dyspepsia post Mini-Gastric Bypass (MGB,
Billroth II) 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 6,253 MGB patients, bile routinely flows
across their BII with No symptoms.

18. Introduction
All patients with a Gastro-jejunostomy
(Roux-en Y or Billroth II) 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
Gastritis or Marginal Ulcer

19. Marginal Ulcer has been known since the beginning
GI Surgery
 THE ROENTGEN DIAGNOSIS & LOCALIZATION
OF
MARGINAL PEPTIC ULCER
 Carman RD.
 Cal State J Med. 1920 Nov;18(11):377-82
 Not New to the Mini-Gastric Bypass

20. 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
 Not New to the Mini-Gastric Bypass

21. 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
 Not New to the Mini-Gastric Bypass

22. 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
 Not New to the Mini-Gastric Bypass

23. Marginal Ulcer Well Know Complication of RNY
Gastric Bypass
 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

24. 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 & 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.

25. Understanding
Normal Physiology of the
Gut
In the Mini-Gastric Bypass
Bile, Bile Reflux, Bile Reflux Gastritis/Esophagitis
Acid Peptic Disease, Marginal Ulcer
Gastritis & Esophagitis After MGB/RNY

26. MGB/Bile Basics
Commonly Misunderstood
• Widspread Confusion: Bile, Bile Reflux, Bile Reflux Gastritis/Esophagitis
• 100% of MGB Patients can Easily Experience
Bile Reflux & Vomiting
• Example: 10 pm Moderate/Large Quantity of
Pasta/Rice/Bread for Dinner =>
Bulky fiberous bolus rapidly dumped to afferent limb
• => Relative Obstruction
• => 12pm Bedtime => Bilious Vomiting & Aspiration
• Simple Rx: NOT RNY, Modify Eating Pattern
No Pasta/Rice/Bread 10pm Dinner

27. Dyspepsia after MGB/Billroth II
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.)

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

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

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

31. 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

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

33. 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).

34. 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).

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

36. Confusion
Danger of MGB Patient Being Mismanaged
Widespread Confusion by Patients &
Especially RNY/Sleeve Surgeons
Bile
Bile Reflux
Bile Reflux Gastritis ***
Marginal Ulcer
Acid Peptic Disease in MGB vs RNY

37. Confusion
Danger of MGB Patient Being Mismanaged
Widespread Confusion by Patients &
Especially RNY/Sleeve Surgeons
Bile Reflux Gastritis ***
Common Error:
If Bile Seen in the Stomach
=> Dx Bile Reflux Gastritis
Wrong!
Bile in the Stomach is Normal!!!

38. Bile Reflux Gastritis Confusion
Danger of MGB Patient Being Mismanaged
Error: Dx Bile Reflux Gastritis
Common Error:
Bile in Stomach Does NOT
= Bile Reflux Gastritis
Wrong!
Bile in the Stomach is Normal!!!

39. Bile Reflux Gastritis Confusion
Danger of MGB Patient Being Mismanaged
Common Error: Dx Bile Reflux Gastritis
Common Error: Bile in Stomach
Does NOT = Bile Reflux Gastritis
Danger: Evaluation of MGB Patient w Dysphagia
by RNY/Sleeve Surgeon
Surgery: Revision of MGB to RNY
Error: Unnecessary Surgery

40. Bile Reflux Gastritis Confusion
Danger of MGB Patient Being Mismanaged
Common Error: Dx Bile Reflux Gastritis
Common Error:
Bile in Stomach + Gastritis Does NOT
= Bile Reflux Gastritis
Wrong!
Bile in the Stomach + Gastritis
*** Usually Acid Peptic Disease ***

41. Gastritis/Marginal Ulcer
in RNY vs MGB
•RNY Marginal Ulcer 5%
• NO Bile
•MGB Marginal Ulcer 5%
• with Bile
•General Surgery
Surgery for Bile Reflux Gastritis
Rare

42. MGB Dysphagia Protocol
• MGB Dysphagia (Nausea, Midepigastric Pain, Vomiting, Bile
Vomiting/Aspiration, Gastritis, Esophagitis, etc.)
• Step 1: 1 Week Diet Hx (See Next Slide)
• Step 2: Optimize Diet, Supplements, Medications,
Alcohol, Smoking, NSAIDs, Steroids, “Herbs” etc.,
Exercise, Sun Exposure, Micronutients & Vitamins
• => Success < 90+%
• => Fail < 10%
• Step 3: Next...

43. NON Surgery Rx MGB Patient with Dysphagia
Simple Lifestyle Changes
1. Plain Yogurt / Curd / Fermetted Dairy:
Minmal 1-2 tsps 6 x
/ Day
2. Stop smoking, NSAIDs, Iron,
“Supplements”
3. Vitamins & Medications Before Meals
4. Stay upright after eating
5. Small meals
6. Limit fatty foods
7. Avoid problem food & Drink:
caffeinated and carbonated
drinks, chocolate, citrus
juices, vinegar dressings &
mint.
8. Limit or avoid alcohol
9. Lose weight
10. Raise Head of Bed with
blocks or sleeping on a foam
wedge
11. Relaxation

44. NON Surgery Rx MGB Patient with Dysphagia
Drug & Probiotic Rx
• Antibiotic Rx to kill H. pylori
• Proton pump inhibitors
• Acid blockers — Histamine (H-2) blockers
• Antacids that neutralize stomach acid
• Probiotics: Help Rx H. Pylori gastritis & ulcers
Probiotic foods, including cultured veggies, kombucha, Yogurt & kefir
etc...
• NO Surgery

45. Rutledge's MGB Results
• 6,000 + MGB Patients
• Dysphagia +20% / Marginal Ulcer 5-7%
• Non-Surgical vs Surgical Rx
=> Non-Surgical Rx Success > 98%
=> Surgical Rx 1%

46. Rutledge's MGB Results
• 6,000 + MGB Patients
• Dysphagia +20% / Marginal Ulcer 5-7%
• Referral to RNY/Sleeve Surgeon
• Surgery Rx : Revision MGB => RNY
MAJOR Weight Regain

47. MGB Dysphagia / Gastritis
• NON Operative Management
Successful > 90%
• MGB surgeons & Patients Need to Understand
Liklehood of Dyspahgia/Gastritis Treatment
• Consider Avoiding Evaluation by RNY/Sleeve
Surgeon
to avoid unecessary surgery

48. 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