Persistent Melena Unmasking an Initially Missed Intestinal Adenocarcinoma in the Context of Billroth II Gastrojejunostomy: a case report

Background Billroth II gastrojejunostomy is a procedure that can be performed for tumors or severe peptic ulcer disease in the distal stomach. Case presentation We present the case of a 68-year-old Caucasian female with a history of Billroth II gastrectomy (33 years ago) who presented with recurrent melena of 4 months’ duration, accompanied by epigastric pain and nausea. Multiple gastroscopies and colonoscopies were inconclusive. However, an endoscopy at a different institution revealed a 4 cm jejunal adenocarcinoma obstructing the afferent loop (figures 1 and 2), which was later excised. In the current literature, many cases describe various sources of bleeding following a Billroth II gastrectomy. Of these sources, it is important to consider malignancy within the afferent loop of a Billroth II reconstruction as a cause. In case there are no detected causes of bleeding, advanced imaging or re-evaluation by endoscopy should be considered. Moreover, yearly endoscoping screening seems to be beneficial to rule out new malignancies, as there is an increased risk due to biliary reflux. Indeed, it is challenging to diagnose such malignancies, especially in those who are asymptomatic. Such high-risk patients need to be followed up in the long-term for early detection and prevention of malignancy. Conclusion This case serves as a reminder of the complex anatomy of Billroth II gastrectomy and its long-term complications, in addition to the need for close follow-up and clinical awareness of possibly missed tumors.