Non-marginal jejunal ulcer perforation following Roux-en-Y gastric bypass

We present a rare case of a jejunal ulcer perforation in the alimentary limb ~15 cm distal to the gastro-jejunal anastomosis on the background of a previous Roux-en-Y gastric bypass (RYGB) 4 months prior to presentation. Marginal ulcer is the most common cause of jejunal perforation following RYGB. However, this is usually confined to the first few centimetres, and the incidence is highest within the first month following surgery. Other risk factors include smoking and non-steroidal anti-inflammatory drug use, Helicobacter pylori infection, trauma, foreign body ingestion, Crohn's disease, typhoid, tuberculosis and malignancy. This case does not possess any of these risk factors and thus represents a unique presentation. Not all jejunal ulcers will present with classical risks factors but still will need to be excluded, given their life-threatening nature. Also, the whole alimentary limb can be susceptible to ulceration; therefore, a thorough investigation of this limb is important to exclude perforation.