Question: Dear Doctor,
XXXX had Roux-en-Y gastric bypass in 2003 and experienced a marginal ulcer afterwards and was given Carafate to successfully treat the symptoms. As time passed, she would experience recurring stomach pain, tell me her ulcer was acting up again, and take Carafate until the pain subsided. She is a psych RN and works in a high stress environment which seemed to correlate with the onset of stomach pain. She worked a seasonal schedule, 3 to 6 months on, a break, then 3 to 6 months again. The pain generally intensified when she was working on the psych unit but was kept under control when taking the medication. Symptoms generally subsided after a month or so of being off. Several years ago, in 2010-11, she was diagnosed severely anemic. She was sent to a facility several times to receive infusions to return her blood levels to normal. In 2012 as in years past, she underwent a pre-work physical with the normal blood and drug tests and passed. She returned to working at the psych ward and was not experiencing any significant levels of stomach pain and described her health as ‘feeling really good’ when she started the new contract extension. She had just extended her contract to work another month when she was injured and was immediately prescribed a corticosteroid for the inflammation that was to follow. She took a 60mg dose of a corticosteroid at 2:00 PM, she took another 60mg dose the next morning at about 6:30 PM and by 1:00 PM that day, less than 24 hours from the time of the first dose, she developed a ruptured duodenum ulcer with no noticeable symptoms during the week prior to the incident.
1. My question is this, given that the patient had previously experienced anemia and frequent stomach pain that subsided when taking the Carafate, is it likely that she had an ulcer in the duodenum at the time of the incident when she began taking the corticosteroid and that the rupture occurred due to the effects of the a corticosteroid?
2. Having had a gastric bypass, wouldn’t it be extremely hard to diagnose a duodenum ulcer since the dissected part of the stomach can’t be reached by a scope?
3. Wouldn’t peptic ulcer symptoms in the dissected part of the stomach be different for someone with a gastric bypass since the acid can only leave the dissected part of the stomach downward thru the duodenum into the small intestines?
4. After searching PubMed extensively, and having found numerous cases where corticosteroids were thought to be the cause of gastric problems, including ulcers, have you experienced such cases in your practice of medicine?
5. Have you had a lot of experience with patients with bypass surgery?
6. For what field or specialty are you board certified?

Thank you for your help Dr. Kini. I'm trying to get several different specialist to look at my question and give me their opinion. Her primary physician agreed with you that it was most likely she had the ulcer at the time the corticosteroid was taken. She presented to an ER immediately following the severe pain and was mis-diagnosed with gastritis. She refused to go back (she is a very stubborn RN) until 72 hours later. It's a wonder she is still alive. Thanks again for your help.
One last question, have you had patients who've had adverse reactions to corticosteroids that affected the gastric system? Like thinning of the stomach lining?

XXXX