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Background

The patient is a 75-year-old man with a history of a gastric bypass who was diagnosed with a diffuse large B Cell lymphoma. He subsequently developed melena and anemia three months into treatment. Multiple conventional and advanced endoscopic techniques failed to intubate his biliopancreatic limb and did not identify a source of bleeding. We took the patient to the operating room in conjunction with an advanced endoscopist for a laparoscopic-assisted endoscopy to diagnose the source of his upper GI bleed. After obtaining laparoscopic access, we mobilized the gastric remnant. The posterior wall of the gastric remnant was inseparable from the superior border of the pancreas. We were able to mobilize the remnant enough to secure it to the abdominal wall for the endoscopy. On endoscopy we found a large posterior ulcer with adherent clot and the splenic artery abutting the ulcer. An attempt to coagulate smaller vessels in the ulcer base led to massive hemorrhage from the splenic artery, necessitating conversion to a laparotomy and suture ligation of the splenic artery. We then completed the remnant gastrectomy and performed a splenectomy due to the devascularization of the spleen. The patient recovered well postoperatively with resolution of his melena and anemia.Conclusions: Gastric remnant ulcer disease is rare. Laparoscopic-assisted endoscopy is a safe and feasible way to diagnose and potentially treat gastric remnant ulcers.