Previously healthy young woman arrived at the ER complaining of left abdominal pain. Labs and urinalysis were normal. History notable for sleeve gastrectomy over 2 years earlier, followed by mini gastric bypass after 3 months, and cholecystectomy.
CT abdomen showed a small marginal ulcer with a very small amount of free intraperitoneal gas bubbles and fluid. She was successfully treated conservatively with fluids, analgesics, and 2 types of antibiotics. As her symptoms were abating, the gastroenterologist wished to do a repeat CT with oral contrast to rule out a macroperforation. The second CT showed that there was indeed no macroperforation and that the ulcer was now "covered". She was sent home after several days, where she started taking a proton pump inhibitor and completed the antibiotic regimen. She underwent gastroscopy after a month, which showed that the ulcer had healed. Stomach biopsy tested negative for H. pylori.

A marginal ulcer is an ulcer that can appear on the intestinal side of a gastrojejunal anastomosis, with an incidence rate of about 15%. Most occur within one year after surgery. There are several factors that can contribute to their occurrence, such as smoking, alcohol, steroid or NSAID use, and diabetes. Suspicion of marginal ulcer should prompt endoscopic investigation.