A gastric ulcer at the anastomosis site perforated into the liver 3 years after Roux-en-Y gastric bypass surgery.

A 44-year-old woman underwent gastric bypass surgery in 2004. One year later, she began to complain of intermittent melena associated with nausea and right upper quadrant (RUQ) pain, which required 1 to 2 units of packed red blood cell transfusions per year. In July 2007, she presented to the emergency department with 2 episodes of bright red blood per rectum associated with syncope. Upper endoscopy was performed and revealed a large ulcer at the anastomosis site, with a visible bleeding vessel, which was cauterized. After recovery from the GI bleeding, the patient requested the reversal of her gastric bypass because of significant weight loss and complications of bleeding and nausea; she weighed 95 pounds at the time. Reversal of the gastric bypass surgery initially was scheduled to be done 4 weeks later as an outpatient procedure. Three weeks later, however, she again presented to the emergency department with hematemesis and melena. Physical examination revealed RUQ tenderness, without guarding or rebound