Carolinas Research Day 2021

Case Report: Small Bowel Obstruction Secondary to Afferent Loop Syndrome Malka Fox-Epstein OMS-III, Michael Hill MD The Regional Medical Center, Orangeburg, SC . Abstract Case Report

Abstract # CBR-8

Discussion

Afferent loop syndrome is a rare complication that can occur after various upper gastrointestinal procedures involving anastomosis of the stomach to the jejunum. Up to 1% of patients who undergo partial gastrectomy with Billroth II or Roux- en-Y reconstruction will experience afferent loop syndrome. 1 Although the majority of afferent loop syndromes present in the early postoperative period, there are accounts of chronic afferent loop syndrome presenting years after gastrectomy. 2 This case report describes a 53-year-old-male with a prior Billroth II anastomoses 10 years ago, who presented with severe abdominal pain and rectal bleeding associated with nausea and bilious vomiting. A CT of the abdomen and pelvis revealed a vastly dilated fluid filled proximal small bowel and markedly distended stomach, consistent with a closed loop obstruction. Intraoperatively, the patient underwent an esophagogastroduodenoscopy that showed a stricture at the anastomosis and reconstruction with a Roux-Y anastomosis was performed immediately. The patient had an uneventful postoperative course and recovered well. Key words: afferent loop syndrome, Billroth II, gastrectomy, chronic afferent loop syndrome, treatment afferent loop syndrome Afferent loop syndrome is a rare cause of mechanical bowel obstruction that can occur after GI procedures involving anastomosis of the stomach to the jejunum. Afferent loop syndrome occurs as a result of complete or partial obstruction of the afferent limb. Approximately 1% of patients who undergo partial gastrectomy with Billroth II or Roux- en-Y reconstruction will experience afferent loop syndrome. 1 Most patients with afferent loop syndrome present early in the postoperative period, however there are accounts of afferent loop syndrome occurring many years after gastrectomy. 2 Acute afferent syndrome will present with severe abdominal pain with nausea and vomiting, tenderness in the right upper quadrant and involuntary guarding. Chronic afferent loop syndrome generally presents with postprandial abdominal discomfort that is relieved with bilious emesis. Many patients will experience weight loss and malabsorption due to bacterial overgrowth. 4 On examination, patients will have right upper quadrant tenderness and involuntary guarding. Abdominal CT is the mainstay of diagnosis in afferent loop syndrome, showing a c-loop sign, which represents a dilated afferent limb, and a keyboard sign, which shows the projection of the valvulae connivenetes into the lumen. 5 Magnetic resonance cholangiopancreatography (MRCP) can also be used in patients who are unable to receive iodinated contrast or ionizing radiation. 6 Afferent loop syndrome due to benign causes is treated with nasogastric tube drainage while patients are resuscitated for surgery. In the event of malignancy, initial treatment with neoadjuvants is followed by surgical intervention. 4 Surgical intervention such as converting a Billroth II to a Roux-en-Y or excising and reconstructing redundant loops are standard. 7 Multiorgan failure due to sepsis and peritonitis is a major complication of acute afferent loop syndrome. Chronic afferent loop syndrome places the patient at risk for malnutrition and anemia as well as anastomotic leak, recurrent adhesions, fistula formation, wound infection, DVT and pulmonary embolism. 7 Introduction

A 53-year-old male with past medical history of right nephrectomy secondary to kidney stones and atrophy, peptic ulcer disease status post Billroth II, orchitis, hypertension, generalized anxiety disorder and cholecystectomy due to choledocholithiasis presented to the emergency room with severe abdominal pain and bloody stool. He had nausea but denied fever, chills, diarrhea, constipation. He reported intermittent postprandial abdominal pain relieved by bilious emesis since the Billroth II anastomosis 10 years prior. He was a current everyday smoker and admitted to excessive alcohol consumption. On physical examination, he was bradycardic and tachypneic but otherwise hemodynamically stable. His abdomen was soft, nontender, nondistended and had normal bowel sounds. A CT was performed that showed an abnormally dilated loop of proximal small bowel with a swirled appearance of the upper mesentery and vascular pedicle with transition in the right upper quadrant highly suggestive of a closed loop obstruction (figure 1). The stomach was also markedly distended and air in the biliary tree suggested previous biliary intervention (figure 2). Additionally, a right sided nephrectomy and a small nonobstructing kidney stone in the left kidney hilum were noted. The patient was diagnosed with a closed loop bowel obstruction and admitted. Laboratory blood tests upon admission showed leukocytosis (12.9 x10 9 Cells/L) with elevated alkaline phosphatase (165 unit/L) and lipase (369 unit/L). A nasogastric tube was placed and intravenous fluids were started. Morphine was given for pain control and protonix as ulcer prophylaxis. An additional small bowel follow through X-ray study was performed and was negative for small bowel obstruction, but a stricture was suspected.

References This case demonstrated an archetypal presentation of acute on chronic afferent loop syndrome. The patient had a previous history of gastrectomy and presented with severe abdominal pain and history of postprandial bilious emesis that relieved pain. Although most afferent loop syndromes present early in the postoperative period, there are cases of afferent loop syndrome occurring years after gastrectomy, as in this patient. The diagnosis of afferent loop syndrome can be difficult but should be suspected in patients who previously underwent gastric surgery. Patients who have an incomplete obstruction tend to have bilious vomit. In complete obstructions, patients do not vomit because the bowel is completely obstructed. An interesting caveat to this case is that the small bowel follow through was negative, indicating an obstruction that allowed some contrast to pass through. This could be a reason as to why this patient’s symptoms persisted for many years before he presented as an emergency. Patients with chronic afferent loop syndrome typically have malnutrition and weight loss, as did this patient. This patient also presented with elevated alkaline phosphatase and lipase, which is characteristic of increased intraluminal pressure in afferent loop syndrome. Although not present in this patient, perforations and peritonitis can ensue if not addressed quickly. Early diagnosis and treatment are necessary to prevent mortality. Afferent loop syndrome can be caused by many things including: internal herniation, kinking at the anastomotic site, adhesions, stomal stenosis, a gastrointestinal stone, recurrent malignancy, and volvulus. 9 In this patient, afferent loop syndrome occurred due to a stricture at the anastomotic site. Management for patients with afferent loop syndrome largely depends on the underlying etiology. Nasogastric tube provides temporary relief; however, surgery is a definitive treatment for benign causes. The present patient was given a nasogastric tube and underwent an open conversion of a Billroth II to a Roux-en-Y with complete resolution. 1- Cao Y, Kong X, Yang D, Li S. Endoscopic nasogastric tube insertion for treatment of benign afferent loop obstruction after radical gastrectomy for gastric cancer: A 16-year retrospective single-center study. Medicine (Baltimore). 2019 Jul;98(28):e16475 2-Uriu Y, Kuriyama A, Ueno A, Ikegami T. Afferent loop syndrome of 10 years' onset after gastrectomy. Asian J Surg. 2019 Oct;42(10):935-937. doi: 10.1016/j.asjsur.2019.06.008. Epub 2019 Jul 10. PMID: 31301932. 3- Katagiri H, Tahara K, Yoshikawa K, Lefor AK, Kubota T, Mizokami K. Afferent Loop Syndrome after Roux-en-Y Total Gastrectomy Caused by Volvulus of the Roux-Limb. Case Rep Surg. 2016;2016:4930354. 4- Blouhos K, Boulas KA, Tsalis K, Hatzigeorgiadis A. Management of afferent loop obstruction: Reoperation or endoscopic and percutaneous interventions? World J Gastrointest Surg. 2015 Sep 27;7(9):190-5. 5- Ramos-Andrade D, Andrade L, Ruivo C, Portilha MA, Caseiro-Alves F, Curvo-Semedo L. Imaging the postoperative patient: long-term complications of gastrointestinal surgery. Insights Imaging. 2016 Feb;7(1):7-20. 6- Takata K, Anan A, Umeda K, Sakisaka S. Magnetic resonance cholangiopancreatography for afferent loop syndrome. Clin Case Rep. 2019 Mar;7(3):591-592. 7- Grotewiel RK, Cindass R. Afferent Loop Syndrome. [Updated 2020 Jun 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. 8- Termsinsuk, P., Chantarojanasiri, T. & Pausawasdi, N. Diagnosis and treatment of the afferent loop syndrome. Clin J Gastroenterol 13, 660–668 (2020). https://doi.org/10.1007/s12328-020-01170-z 9-Afferent loop obstruction after distal gastrectomy with Roux-en-Y reconstruction. Aoki M, Saka M, Morita S, Fukagawa T, Katai H . World J Surg. 2010 Oct; 34(10):2389-92.

Figure 2: Markedly distended stomach.

Figure 3: The proximal jejunal limb draining the duodenum was dilated at least 6 to 7 centimeters and thickened

Figure 1: Abnormally dilated loop of small bowel.

The patient underwent an esophagogastroduodenoscopy that showed a stricture at the gastrojejunostomy anastomosis and exploratory laparotomy was subsequently performed. The patient had a distended stomach which was decompressed using a nasogastric tube. The proximal jejunal limb draining the duodenum from the ligament of Treitz was dilated at least 6 to 7 centimeters and thickened (figure 3). The patient had an obvious stricture at the gastrojejunostomy anastomosis at the stomach. The small bowel was decompressed, and the proximal and distal limbs of the jejunum were also resected in order to remove the anastomosis completely. The distal small bowel was then brought up to the stomach and connected with a side-to-side anastomosis. The proximal jejunal limb draining the duodenum was brought downstream and sewn to the small bowel to create a Roux-en-Y anastomosis. A feeding jejunostomy tube was placed. Post-operatively, the patient had a nasogastric tube placed to help with post-operative ileus, but this was removed on post-operative day 2, and the patient recovered well. Pathology showed mucosal ulceration, fibrosis, vascular congestion and focal subserosal hemorrhage with no evidence of perforation or peritonitis. The remainder of the post-operative course was uneventful, and the patient was discharged on post-operative day 6. The patient was followed up in the office one week after discharge without complaints.

Acknowledgements

Special acknowledgements to The Regional Medical Center- Orangeburg SC, VCOM- Carolinas, and Isabella Moncada.

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