Marginal ulcer is a relatively common complication after gastric bypass, but remnant gastroduodenal ulcers are less common and difficult to diagnose given access to the remnant stomach is challenging. Perforations of both marginal ulcers and duodenal ulcers can occur, but the latter can pose a diagnostic challenge since typical findings on imaging, such as contrast extravasation or free air, may not be as easily seen as in the former. We present a case of a perforated duodenal ulcer after gastric bypass and steps of operative management.


36-year-old female with a history of tobacco abuse who had undergone a laparoscopic gastric bypass 14 years prior with subsequent laparoscopic internal hernia repair presented with severe abdominal pain, lactic acidosis and CT scan findings concerning for a duodenal perforation. She underwent emergent successful laparoscopic modified Graham patch repair of the ulcer with remnant gastrostomy tube placement. The patient had an uneventful recovery and was discharged on postoperative day 6.


Duodenal ulcer perforation after gastric bypass is an uncommon finding relative to marginal ulcer perforation. Early diagnosis is imperative, and management can often be achieved with a minimally invasive approach with good outcomes. Remnant gastrostomy decompression may aid in the success of the repair.