Figure 3.77. Dilatation of the distal stomach after gastric bypass. (A) Contrast study shows a dilated air- and fluid-filled bypassed portion of stomach. (B, C) CT scans on a different patient showing a markedly distended bypassed portion of stomach.

Indications for examination of the distal stomach include persistent nausea, vomiting, epigastric pain, and upper GI bleeding. Several percutaneous techniques for examination of the distal stomach have been described [75-77]. The distal stomach can be localized by using CT imaging, fluoroscopy in combination with [99Tc] pertechnetate scanning, or sonography. In the technique described by McNeely et al., the patient is given [99mTc] pertechnetate and the stomach is visualized on the gamma camera and outlined on the skin with a cotton swab labeled with the isotope and an ink marker [77]. Some surgeons place clips on the greater and lesser curvatures of the antrum at the time of surgery. Assisted by previous barium studies, hemoclip markers, previous gas-trostomy scarring, and the radionuclide localization, a 22-gauge needle is advanced under fluoroscopic guidance and water-soluble contrast medium is introduced to identify the stomach. When the needle is in good position, additional contrast medium is administered and spot films obtained. CT imaging and sonography have also been used to localize the distal stomach, and fluoroscopy proceeds once the needle is in place. Gastritis, inflammatory changes of the distal stomach, and ulcers may be identified with these techniques. Endoscopy can also be performed after GBP with a pediatric endoscope, although this procedure is technically difficult.

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