Recurrent Pancreatitis Caused by Afferent Loop Syndrome with Pathologic Features of Type II Autoimmune Pancreatitis / 대한내과학회지

Afferent loop syndrome (ALS) is a rare cause of recurrent pancreatitis. Recurrent pancreatitis in association with ALS can develop due to impaired outflow of pancreatic juice or reflux of enteric secretions caused by increased intraluminal duodenal pressure. Here, we report a case of ALS presenting as recurrent acute pancreatitis due to chronic intermittent partial obstruction of the third portion of the duodenum caused by postoperative adhesion. Interestingly, pancreatic histology showed a granulocytic epithelial lesion, which is a diagnostic feature of type 2 autoimmune pancreatitis (AIP, idiopathic duct centric chronic pancreatitis [IDCP]). From this case we learned that the diagnosis of type 2 AIP should be made in the appropriate clinical setting.

Metal Stent Placement in the Afferent Loop Obstructed by Peritoneal Metastases—Experience of Five Cases

Afferent loop syndrome is often difficult to resolve. Among patients with afferent loop syndrome whose data were extracted from databases, 5 patients in whom metal stent placement was attempted were included and evaluated in this study. The procedure was technically successful without any adverse events in all patients. Metal stent(s) was placed with an endoscope in the through-the-scope manner in 4 patients and via a percutaneous route in 1 patient. Obvious clinical efficacy was observed in all patients. Adverse events related to the procedure and stent occlusion during the follow-up period were not observed. Metal stent placement for malignant obstruction of the afferent loop was found to be safe and feasible.

The obstructed afferent loop: Percutaneous options

Endoscopic drainage can be considered the treatment of choice in benign and malignant obstruction of the distal biliary tree, with percutaneous intervention reserved for cases of difficult access or complex hilar strictures. However in patients with altered anatomy due to pancreatico-duodenectomy gastrectomy, or Bilroth II reconstruction, endoscopy can be exceptionally challenging and often impossible. Surgery remains the gold standard for benign causes of obstruction of a bilio-enteric anastomosis or afferent loop, and percutaneous management remains controversial. Novel endoscopic techniques such as double balloon enteroscopy and endoscopic ultrasound guided procedures can overcome some of the anatomical challenges, but a percutaneous approach is a more established technique for cases of malignant obstruction of a bilio-enteric anastomosis or afferent loop. The altered anatomy presents unique challenges which must be fully contemplated and understood before intervention should occur, to avoid the risk of permanent external drainage.

Deep vein thrombosis caused by malignant afferent loop obstruction / 영남의대학술지

Afferent loop obstruction following gastrectomy is a rare but fatal complication. Clinical features of afferent loop obstruction are mainly gastrointestinal symptoms. A 56-year-old female underwent radical total gastrectomy with Roux-en-Y esophagojejunostomy for treatment of advanced gastric cancer. After fourteen months postoperatively, she showed gradual development of edema of both legs. Computed tomography (CT) scan showed disease progression at the jejunojejunostomy site and consequent dilated afferent loop, which resulted in inferior vena cava (IVC) compression. A drainage catheter was placed percutaneously into the afferent loop through the intrahepatic duct and an IVC filter was placed at the suprarenal IVC, and selfexpanding metal stents were inserted into bilateral common iliac veins. With these procedures, sympotms related with afferent loop obstruction and deep vein thrombosis were improved dramatically. The follow-up abdominal CT scan was taken 3 weeks later and revealed the completely decompressed afferent loop and improved IVC patency. Surgical treatment should be considered as the first choice for afferent loop obstruction; however, because it is more immediate and less invasive, non-surgical modalities, such as percutaneous catheter drainage or stent placement, can be effective alternatives for inoperable cases or risky patients who have severe medical comorbidities.

RE: Afferent Loop Syndrome: A Rare Clinical Condition Diagnosed with Magnetic Resonance Cholangiopancreatography

No abstract available.

A Case of Afferent Loop Syndrome Treated by Endoscopic Metal Stent Insertion Using Two Endoscopes / 대한내과학회지

Afferent loop syndrome is a rare complication of pancreaticoduodenectomy, and the endoscopic approach is difficult due to the surgically altered anatomy. Herein, we report a case of afferent loop obstruction treated by endoscopic metal stent insertion using two endoscopes. A 57-year-old male who had undergone the Whipple operation 7 months prior for pancreatic head cancer presented with abdominal pain and jaundice. Abdominal computed tomography showed afferent loop obstruction due to recurrent metastatic pancreatic cancer. First, we attempted to insert the stent using percutaneous transhepatic approaches following percutaneous transhepatic biliary drainage, but these failed. We therefore accessed the obstruction site using a relatively thin endoscope and then exchanged this endoscope for another with a large working channel, through which the self-expandable metal stent was passed. The stent was inserted successfully. This method will increase the success rate of endoscopic treatment.

Electrohydraulic Lithotripsy of an Impacted Enterolith Causing Acute Afferent Loop Syndrome

Afferent loop syndrome caused by an impacted enterolith is very rare, and endoscopic removal of the enterolith may be difficult if a stricture is present or the normal anatomy has been altered. Electrohydraulic lithotripsy is commonly used for endoscopic fragmentation of biliary and pancreatic duct stones. A 64-year-old man who had undergone subtotal gastrectomy and gastrojejunostomy presented with acute, severe abdominal pain for a duration of 2 hours. Initially, he was diagnosed with acute pancreatitis because of an elevated amylase level and pain, but was finally diagnosed with acute afferent loop syndrome when an impacted enterolith was identified by computed tomography. We successfully removed the enterolith using direct electrohydraulic lithotripsy conducted using a transparent cap-fitted endoscope without complications. We found that this procedure was therapeutically beneficial.

Percutaneous Cholangioscopic Lithotripsy for Afferent Loop Syndrome Caused by Enterolith Development after Roux-en-Y Hepaticojejunostomy: A Case Report

Afferent loop obstruction caused by enterolith formation is rare and cannot be easily treated with endoscopy because of the difficulty associated with the nonsurgical removal of enteroliths. A 74-year-old woman was admitted with fever and acute abdominal pain. Clinical features and imaging studies suggested afferent loop obstruction caused by an enterolith after Roux-en-Y hepaticojejunostomy. Percutaneous transhepatic biliary drainage was initially performed because of severe cholangitis with septic shock. The enterolith was located in the jejunal limb adjacent to the hepaticojejunostomy site. Cholangioscopic lithotripsy was performed through the percutaneous transhepatic route to the enterolith, and the fragments were moved into the efferent loop using scope push and saline flush methods. Here, we describe a case of afferent loop syndrome caused by an enterolith that developed after Roux-en-Y hepaticojejunostomy and was treated with percutaneous transhepatic cholangio-enteroscopic lithotripsy.

Afferent loop obstruction following laparoscopic distal gastrectomy with Billroth-II gastrojejunostomy / 대한외과학회지

PURPOSE: Afferent loop (A-loop) obstruction is an uncommon postgastrectomy complication following Billroth-II (B-II) or Roux-en-Y reconstruction. Moreover, its development after laparoscopic gastrectomy has not been reported. Here we report 4 cases of A-loop obstructions after laparoscopic distal gastrectomy (LDG) with B-II reconstruction. METHODS: Among the 396 patients who underwent LDG with a B-II anastomosis between April 2004 and December 2011, 4 patients had A-loop obstruction. Their data were obtained from a prospectively maintained institutional database and analyzed for outcomes. RESULTS: Four patients (1.01%) developed A-loop obstruction. All were male, and their median age was 52 years (range, 30 to 73 years). The interval between the initial gastrectomies and the operation for A-loop obstruction ranged from 4 to 540 days (median, 33 days). All 4 patients had symptoms of vomiting and abdominal pain and were diagnosed by abdominal computed tomographic (CT) scan. The causes of the A-loop obstructions were adhesions (2 cases) and internal herniations (2 cases) that were treated with Braun anastomoses and reduction of the herniated small bowels, respectively. All patients recovered following the emergency operations. CONCLUSION: A-loop obstruction is a rare but serious complication following laparoscopic and open gastrectomy. It should be considered when a patient complains of continuous abdominal pain and/or vomiting after LDG with B-II reconstruction. Prompt CT scan may play an important role in diagnosis and treatment.

A Case of Afferent Loop Syndrome with Acute Cholangitis Developed after Percutaneous Transhepatic Cholangioscopic Lithotripsy for Treatment of Choledocholithiasis in a Patient Who Underwent Billroth II Gastrectomy / 대한소화기학회지

Afferent loop syndrome is a rare complication which can occur in patients with Billroth II gastrectomy. Bile and pancreatic juice is congested at afferent loop in the syndrome. This syndrome can progress rapidly to necrosis, perforation, or severe sepsis, and therefore early diagnosis and swift surgical intervention is important. But, cases of endoscopic or percutaneous transhepatic drainage have been reported when surgical management was inappropriate to proceed. We report a case of afferent loop syndrome accompanying acute cholangitis developed after percutaneous transhepatic cholangioscopic lithotripsy for the retrieval of common bile duct stone in a patient who underwent Billroth II gastrectomy due to early gastric cancer. There was no other organic cause. We treated afferent loop syndrome successfully by performing balloon dilation of afferent loop outlet.

A Case of Acute Pancreatitis due to Afferent Loop Syndrome with Internal Hernia / 대한소화기학회지

Acute pancreatitis and afferent loop syndrome (ALS) have similar symptoms and physical findings. Accurate early diagnosis is essential, as the management of acute pancreatitis is predominantly conservative whereas ALS usually requires surgery. We experienced one case of pancreatitis due to ALS with internal hernia. Laboratory findings of patient showed elevated serum amylase, lipase and WBC count. One day after admission, diagnosis was modified as acute pancreatitis caused by ALS on computed tomography. Patient was managed with surgical treatment and operation finding revealed ALS due to internal hernia. He was recovered well after surgical treatment and discharged without significant sequelae.

A Case of Primary Duodenal Cancer on Afferent Loop Presenting with Chronic Anemia and Recurrent Melena

Obscure gastrointestinal bleeding accounts for approximately 5% of all gastrointestinal bleeding. Angioectasia of the small bowel is the most common form of obscure gastrointestinal bleeding, while small bowel tumors are the second. Among small bowel tumors, primary duodenal cancer is uncommon and represents 0.3% of gastrointestinal tumors. However, primary duodenal cancer at the duodenal stump following Billroth II gastrectomy for stomach cancer is extremely rare, and have not been reported yet in Korea. We report the first case of a 74-year-old man with chronic anemia and recurrent melena, which was diagnosed as a primary duodenal adenocarcinoma developed in afferent loop. The primary lesion was successfully accessed under cap-fitted endoscopy, however final diagnosis was delayed due to the unusual anatomical site.

Using Multidetector-Row CT for the Diagnosis of Afferent Loop Syndrome Following Gastroenterostomy Reconstruction

PURPOSE: To assess the clinical manifestations and multidetector-row computed tomography (MDCT) findings of afferent loop syndrome (ALS) and to determine the role of MDCT on treatment decisions. MATERIALS AND METHODS: From January 2004 to December 2008, 1,100 patients had undergone gastroenterostomy reconstruction in our institution. Of these, 22 (2%) patients were diagnosed as ALS after surgery that included Roux-en-Y gastroenterotomy (n=9), Billroth-II gastrojejunostomy (n=7), and Whipple's operation (n=6). Clinical manifestations and MDCT features of these patients were recorded and statistically analyzed. The presumed etiologies of obstruction shown on the MDCT were correlated with clinical information and confirmed by surgery or endoscopic biopsy. RESULTS: The most common clinical symptom was acute abdominal pain, presenting in 18 patients (82%). We found that a fluid-filled C-shaped afferent loop in combination with valvulae conniventes projecting into the lumen was the most common MDCT features of ALS. Malignant causes of ALS, such as local recurrence and carcinomatosis, are the most common etiologies of obstruction. These etiologies and associated complications can be predicted 100% by MDCT. CONCLUSION: Our results suggest that MDCT is a reliable modality for assessing the etiologies of ALS and guiding treatment decisions.

Endoscopic Management of Afferent Loop Syndrome after a Pylorus Preserving Pancreatoduodenecotomy Presenting with Obstructive Jaundice and Ascending Cholangitis

Afferent loop syndrome is a rare complication of gastrojejunostomy. Patients usually present with abdominal distention and bilious avomiting. Afferent loop syndrome in patients who have undergone a pylorus preserving pancreaticoduodenectomy can present with ascending cholangitis. This condition is related to a large volume of reflux through the biliary-enteric anastomosis and static materials with bacterial overgrowth in the afferent loop. Patients with afferent loop syndrome after pylorus preserving pancreaticoduodenectomy frequently cannot be confirmed as surgical candidates due to poor medical condition. In that situation, a non-surgical palliation should be considered. Herein, we report two patients with afferent loop syndrome presenting with obstructive jaundice and ascending cholangitis. The patients suffered from the recurrence of pancreatic cancer after pylorus preserving pancreaticoduodenectomy. The diagnosis of afferent loop syndrome was confirmed, and the patients were successfully treated by inserting an endoscopic metal stent using a colonoscopic endoscope.

Endoscopic Management of Afferent Loop Syndrome after a Pylorus Preserving Pancreatoduodenecotomy Presenting with Obstructive Jaundice and Ascending Cholangitis

Afferent loop syndrome is a rare complication of gastrojejunostomy. Patients usually present with abdominal distention and bilious avomiting. Afferent loop syndrome in patients who have undergone a pylorus preserving pancreaticoduodenectomy can present with ascending cholangitis. This condition is related to a large volume of reflux through the biliary-enteric anastomosis and static materials with bacterial overgrowth in the afferent loop. Patients with afferent loop syndrome after pylorus preserving pancreaticoduodenectomy frequently cannot be confirmed as surgical candidates due to poor medical condition. In that situation, a non-surgical palliation should be considered. Herein, we report two patients with afferent loop syndrome presenting with obstructive jaundice and ascending cholangitis. The patients suffered from the recurrence of pancreatic cancer after pylorus preserving pancreaticoduodenectomy. The diagnosis of afferent loop syndrome was confirmed, and the patients were successfully treated by inserting an endoscopic metal stent using a colonoscopic endoscope.

Pancreatitis aguda secundaria a síndrome de asa aferente / Acute pancreatitis secondary to afferent loop syndrome: report of one case

We report a case of a 59 years old male patient, operated in our service for an Acute Pancreatitis secondary to an Afferent Loop Syndrome. According to the literature we evaluated the low incidence of this entity, the difficulty on the clinical diagnosis, supported by the imagenologic fmdings and the different surgical options.

Se presenta el caso de un paciente de 59 años operado en nuestro servicio por un cuadro de pancreatitis aguda secundario a un síndrome de asa aferente agudo. Se comenta en base a la literatura la baja frecuencia en que se presenta esta entidad actualmente, su presentación clínica inespecífica, haciendo énfasis en el apoyo radiológico para llegar al diagnóstico, y las diferentes alternativas de manejo quirúrgico.

A Case of Afferent Loop Syndrome after Inserting a Double-Layered Pyloric Stent for Gastric Outlet Obstruction in a Patient with Stump Gastric Cancer after Undergoing Billroth II Radical Subtotal Gastrectomy / 대한소화기내시경학회지

Stent insertion is an effective method for treating a patient with gastric outlet obstruction that's caused by recurred cancer at the anastomosis site. There are some complications associated with stent insertion, such as perforation, bleeding, ulceration and obstruction. There are only rare Korean case reports of afferent loop syndrome after stent insertion. We report here on a case of afferent loop syndrome that occurred after insertion of a double-layered pyloric stent for gastric outlet obstruction in a patient with stump gastric cancer after undergoing Billroth II radical subtotal gastrectomy.

A Bezoar That Caused Afferent Loop Syndrome and Pancreatitis / 대한소화기내시경학회지

Bezoars are conglomerates of nondigestible matter in the gastrointestinal tract that may or may not be accompanied by gastrointestinal manifestations. Bezoars develop in patients with previous gastric surgery or in those patients with delayed gastric emptying that is due to gastroparesis caused by hypothyroidism or diabetes mellitus. Small bowel obstruction due to a gastric bezoar is rare, but it can lead to severe complications such as intestinal perforation, compression necrosis etc. A female patient came to our department complaining of upper abdominal pain and she was diagnosed as having a bezoar that was causing afferent loop syndrome and pancreatitis. We attempted to manage the patient by inserting a nasogastric tube, performing gastrofibroscopy and implementing percutaneous transhepatic biliary drainage, but the patient's condition worsened and deteriorated into a septic condition. An operation was planned, but the patient showed improvement owing to the migration of the bezoar. Herein, we report on a case of afferent loop syndrome due to bezoar and this was complicated by acute pancreatitis.

A Case of Successful Endoscopic Management of Afferent Loop Leakages by Using Hemoclips and a Detachable Snare / 대한소화기내시경학회지

There are many complications following gastrectomy and one of the most frequent complications is anastomosis site leakage. Postoperative leakage is a serious complication in patients after they undergo gastric surgery. It can lead to the progressive deterioration in the patient's condition and quality of life and the mortality rate is nearly 60%. We encountered a case of a 75 year-old man who had the leakage of the jejunal end of the Roux limb after total gastrectomy. We performed treatment of the leakage endoscopic clipping and detachable snaring. Hemoclips were fixed at the margin of both sides of the lesion. A detachable snare was used to bind both hemoclips, so the interval was made narrow. After snare binding, five hemoclips were used for final closure of the small interval. After treatment, the leakage of the afferent loop end was completely stopped. He resumed an oral intake and was discharged without complications.

A Case of Afferent Loop Syndrome Treated by Endoscopic Drainage Procedure using Nasogastric Tube / 대한소화기학회지

Afferent loop syndrome is an uncommon complication which occurs in patients with Billroth II partial gastrectomy. Clinically, the diagnosis of afferent loop syndrome may be difficult to establish and thus, depends on the finding of computed tomography, abdominal ultrasound, barium studies and hepatobiliary scan. When the diagnosis is made, most of the cases are treated by surgical operation. We present a case of 67-year-old male patient with afferent loop syndrome associated with acute pancreatitis which was treated by endoscopic drainage procedure using a nasogastric tube.