Cholangitis secondary to afferent loop syndrome from a gastric stump adenocarcinoma.

A clinical case of an 85-year-old patient with cholangitis secondary to afferent loop syndrome from gastric stump adenocarinoma. A brief review of the literature on it is made.

Colangitis secundaria a síndrome de asa aferente por adenocarcinoma sobre el muñón gástrico / Cholangitis secondary to afferent loop syndrome from a gastric stump adenocarcinoma

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Endoscopic management of afferent loop syndrome caused by enteroliths and anastomotic stricture. A case report

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Recurrent cholangitis by biliary stasis due to non-obstructive afferent loop syndrome after pylorus-preserving pancreatoduodenectomy: report of a case.

We report a 71-year-old man who had undergone pylorus-preserving pancreatoduodenectomy (PPPD) using PPPD-IV reconstruction for cholangiocarcinoma. For 6 years thereafter, he had suffered recurrent cholangitis, and also a right liver abscess (S5/8), which required percutaneous drainage at 9 years after PPPD. At 16 years after PPPD, he had been admitted to the other hospital because of acute purulent cholangitis. Although medical treatment resolved the cholangitis, the patient was referred to our hospital because of dilatation of the intrahepatic biliary duct (B2). Peroral double-balloon enteroscopy revealed that the diameter of the hepaticojejunostomy anastomosis was 12 mm, and cholangiography detected intrahepatic stones. Lithotripsy was performed using a basket catheter. At 1 year after lithotripsy procedure, the patient is doing well. Hepatobiliary scintigraphy at 60 minutes after intravenous injection demonstrated that deposit of the tracer still remained in the upper afferent loop jejunum. Therefore, we considered that the recurrent cholangitis, liver abscess, and intrahepatic lithiasis have been caused by biliary stasis due to nonobstructive afferent loop syndrome. Biliary retention due to nonobstructive afferent loop syndrome may cause recurrent cholangitis or liver abscess after hepaticojejunostomy, and double-balloon enteroscopy and hepatobiliary scintigraphy are useful for the diagnosis of nonobstructive afferent loop syndrome.

[A case of remnant gastric cancer with afferent loop syndrome treated by left upper exenteration].

A 64-year-old man with sudden upper abdominal pain and emesis was admitted to our hospital. Forty years ago, he had undergone distal gastrectomy and reconstruction by Billroth II anastomosis for gastric cancer. Abdominal computed tomography revealed a dilated afferent loop and anastomotic tumor. Gastrofiberscopy showed crookedness and edematization of the afferent loop anastomosis. A biopsy revealed a poorly differentiated adenocarcinoma. He was operated on under the diagnosis of remnant gastric cancer. Left upper exenteration was performed because the transverse colon, lateral segment of the liver, pancreas, and left renal hilus were involved. Liver metastasis and abdominal dissemination were not observed. Histopathological findings revealed severe invasion of poorly differentiated adenocarcinoma to other organs, and intraoperative peritoneal lavage cytology was positive. He was discharged from our hospital; however, adjuvant chemotherapy was impossible because of his poor condition. Four months after the operation, he died from peritoneal carcinomatosis. Remnant gastric cancer with afferent loop syndrome has a poor prognosis. Therefore, it is necessary to select surgical resection or palliative care after immediate chemotherapy, considering each patient's condition and cancer stage.

Primary sclerosing cholangitis is associated with endoscopic and histologic inflammation of the distal afferent limb in patients with ileal pouch-anal anastomosis.

BACKGROUND: We hypothesized that patients with primary sclerosing cholangitis (PSC) may have a higher risk for prepouch ileitis in the setting of ileal pouch-anal anastomosis (IPAA). The aim of this study was to compare endoscopic and histologic inflammation in the afferent limb (prepouch ileum) and pouch between IPAA patients with and without PSC. METHODS: In all, 39 consecutive inflammatory bowel disease (IBD) and IPAA patients with PSC (study group) were identified and 91 IBD and IPAA patients without PSC (control group) were randomly selected with a 1:2 ratio. Demographic, clinical, endoscopic, and histologic variables were analyzed. RESULTS: There were no significant differences in age, gender, and nonsteroidal antiinflammatory drug use between the study and control groups. Twelve (30.8%) patients in the IPAA-PSC group had coexisting autoimmune disorders, in contrast to five (5.5%) patients in the IPAA control group (P < 0.001). More patients in the study group had endoscopic inflammation as demonstrated by the higher Pouchitis Disease Activity Index (PDAI) endoscopic scores of the afferent limb and pouch body than those in the control group (P = 0.02 and P < 0.001, respectively). In addition, more patients with PSC had higher PDAI histologic scores of the afferent limb than those without PSC (P < 0.001). Multivariate analysis showed higher PDAI endoscopy and histology subscores were associated with risk for PSC, with odds ratio 1.34 (95% confidence interval [CI]: 1.34, 3.79) and 1.61 (95% CI: 1.00, 2.58), respectively. CONCLUSIONS: Concurrent PSC appears to be associated with a significant prepouch ileitis on endoscopy and histology in patients with IPAA. Pouch patients with long segment of ileitis should be evaluated for PSC.

[A case of acute pancreatitis due to afferent loop syndrome with internal hernia].

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 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.

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.

Oclusión intestinal: nuestra experiencia en el tratamiento quirúrgico / Bowel obstruction: authors' experience with the surgical management

El síndrome de Oclusión Intestinal representa entre un 20 % y 30 % de los cuadros de Abdomen Agudo. El objetivo es relacinar edad, sexo, riesgo ASA, altura de la oclusión, retardo en el tratamiento quirúrgico con mortalidad, complicaciones médicas y quirúrgicas. Se realizú en el Servicio de Guardia Central H:N:C. UNC.. Diseño: estudio prospectivo y protocolizado. Material y métodos: entre enero de 2004 y enero de 2007, se operaron 52 pacientes con un cuadro de oclusión intestinal. Del total 32 de ellos fueron hombres y 20 mujeres; el promedio de edad correspondió a 52,11 años. Riesgo Quirúrgico: el 46,15 % de los pacientes presentó riesgo A.S.A. III, 38,69 % riesgo A.S.A. II, 11,53 % riesgo A.S.A. I y 9,61 % riesgo A.S.A. IV. Los síntomas mós frecuentes fueron dolor abdominal y distensión abdominal y los signos de distensión abdominal y timpanismo abdominal. Resultados: en las Oclusiones altas las Bridas fueron la causa más frecuente y en Oclusiones bajas el Cáncer de sigmoides. La mortalidad global fue de 13,45 %. Respecto de las Complicaciones médicas postquirúrgicas, 14 pacientes en total las presentron, la más frecuente fue la Insuficiencia Renal Aguda con 9 casos. respecto de las complicaciones del acto quirúrgico, 12 pacientes en toal las presentron; las más frecuentes fueron las infecciones de la herida quirúrgica con 7 casos. Conclusiones: el riesgo A.S.A. elevado mostró ser uno de los factores predictivos más importantes respecto del incremento de la mortalidad en cuadros oclusivos de urgencia, junto con la edad y el retraso de la indicación quirúrgica.

Bowel obstruction syndrome represents 20 to 30 % of acute abdominal consult. Objectives: to relate age, gender, ASA risk, large or smal intestinal obstruction, opportunity chirurgic treatment, medical and clinic complications. Establishment: Central Guard Service of N.C.H. of the C.N.U. Design: protocolized and prospective study. Methods and materials: between January 2004 and January 2007 it has been operated 52 patients with acute bowel obstruction, 32 of them were males and 20 females. The middle age eas 52,11 years. Chirurgic risk: 46,15 % had ASA risk III, 38,69 % had ASA risk II, 11,53 % had ASA risk I, and 9,61 % had ASA risk IV. Most common sympotom was abdominal pain and abdominal distension, and the most common signs were distension and tympanic abdominal. Results: the most common cause of small bowel obstruction sigmoid cancer. Global mortality was 13,45 %. Post chirurgic complications: 9 patients had acute renal failure and 7 had wound surgery infection. Conclusions: the most important factors that increase mortality on acute bwel obstructions are elevated risk ASA, age adn retard of surgery treatment.

Oclusión intestinal: nuestra experiencia en el tratamiento quirúrgico / Bowel obstruction: authors experience with the surgical management

El síndrome de Oclusión Intestinal representa entre un 20 % y 30 % de los cuadros de Abdomen Agudo. El objetivo es relacinar edad, sexo, riesgo ASA, altura de la oclusión, retardo en el tratamiento quirúrgico con mortalidad, complicaciones médicas y quirúrgicas. Se realizú en el Servicio de Guardia Central H:N:C. UNC.. Diseño: estudio prospectivo y protocolizado. Material y métodos: entre enero de 2004 y enero de 2007, se operaron 52 pacientes con un cuadro de oclusión intestinal. Del total 32 de ellos fueron hombres y 20 mujeres; el promedio de edad correspondió a 52,11 años. Riesgo Quirúrgico: el 46,15 % de los pacientes presentó riesgo A.S.A. III, 38,69 % riesgo A.S.A. II, 11,53 % riesgo A.S.A. I y 9,61 % riesgo A.S.A. IV. Los síntomas mós frecuentes fueron dolor abdominal y distensión abdominal y los signos de distensión abdominal y timpanismo abdominal. Resultados: en las Oclusiones altas las Bridas fueron la causa más frecuente y en Oclusiones bajas el Cáncer de sigmoides. La mortalidad global fue de 13,45 %. Respecto de las Complicaciones médicas postquirúrgicas, 14 pacientes en total las presentron, la más frecuente fue la Insuficiencia Renal Aguda con 9 casos. respecto de las complicaciones del acto quirúrgico, 12 pacientes en toal las presentron; las más frecuentes fueron las infecciones de la herida quirúrgica con 7 casos. Conclusiones: el riesgo A.S.A. elevado mostró ser uno de los factores predictivos más importantes respecto del incremento de la mortalidad en cuadros oclusivos de urgencia, junto con la edad y el retraso de la indicación quirúrgica.(AU)

Bowel obstruction syndrome represents 20 to 30 % of acute abdominal consult. Objectives: to relate age, gender, ASA risk, large or smal intestinal obstruction, opportunity chirurgic treatment, medical and clinic complications. Establishment: Central Guard Service of N.C.H. of the C.N.U. Design: protocolized and prospective study. Methods and materials: between January 2004 and January 2007 it has been operated 52 patients with acute bowel obstruction, 32 of them were males and 20 females. The middle age eas 52,11 years. Chirurgic risk: 46,15 % had ASA risk III, 38,69 % had ASA risk II, 11,53 % had ASA risk I, and 9,61 % had ASA risk IV. Most common sympotom was abdominal pain and abdominal distension, and the most common signs were distension and tympanic abdominal. Results: the most common cause of small bowel obstruction sigmoid cancer. Global mortality was 13,45 %. Post chirurgic complications: 9 patients had acute renal failure and 7 had wound surgery infection. Conclusions: the most important factors that increase mortality on acute bwel obstructions are elevated risk ASA, age adn retard of surgery treatment.(AU)

Acute afferent loop syndrome: a true emergency. A case report.

Afferent loop syndrome is a relatively rare complication after subtotal gastrectomy. We present a late onset of afferent loop obstruction, in a patient who underwent Billroth II gastrectomy with Roux-Y reconstruction for a gastric ulcer 27 years ago. A 60-year-old male was admitted to the hospital with an 8-hour history of acute epigastric pain, associated with vomiting, fever and signs of sepsis. Laboratory tests revealed leukocytosis, elevated liver function tests and high serum amylase. An obstructed afferent loop appeared on CT as a fluid filled tubular mass, crossing the middle line between the aorta and the mesenteric vessels. Advanced sepsis was also seen in the peripancreatic and retroperitoneal region. Although the patient was operated on immediately after diagnosis with reconstruction of Roux-Y anastomosis, he died 12 hours later. Afferent loop syndrome is quite uncommon, and must be suspected in patients who have undergone subtotal gastrectomy. Clinical manifestations of the syndrome are usually non-specific. CT is the examination of choice and surgery the first choice treatment.

Ictericia secundaria a vólvulo del asa aferente del Billroth-II / Jaundice caused by afferent loop volvulus following Billroth-II gastrectomy

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[A case of acute afferent loop syndrome treated by endoscopic decompression].

A 67-year-old woman underwent distal gastrectomy (Billroth type II reconstruction) for gastric ulcer perforation in March, 2001. In October of the same year, she was admitted to our hospital with a diagnosis of acute afferent loop syndrome with severe acute pancreatitis. The patient was successfully treated by endoscopic decompression of the afferent loop, followed by continuous drainage. Combined use of decompression and percutaneous abscess drainage was effective for the management of the retroperitoneal abscess. The most common treatment strategy employed for acute afferent loop syndrome is surgical therapy, however, the experience in this patient suggests that endoscopic drainage, which is less invasive, may also be considered.

Laparoscopy in afferent loop obstruction presenting as acute pancreatitis.

BACKGROUND: We describe an afferent loop obstruction caused by an adhesion band in a case of distal gastrectomy with Roux-en-Y end-to-side jejunal anastomosis for cancer. METHODS: An initial clinical presentation of acute pancreatitis was ruled out by a computed tomography scan, which revealed intestinal obstruction; it was then confirmed on laparoscopy. Definitive treatment was laparoscopic adhesiolysis. A complete review of the literature concerning afferent loop obstructions is presented. RESULTS: The treatment was successful, with minimal postoperative pain, and the 5-day hospital stay was uncomplicated. The patient remains asymptomatic at 1-year follow-up. CONCLUSIONS: The authors advocate minimally invasive surgery as a complete diagnostic and therapeutic alternative to emergency laparotomy in cases where afferent loop syndrome is suspected, and acknowledge that prompt surgery has a higher rate of success and reduces operative morbidity and mortality.

Enteroliths developed in a chronically obstructed afferent loop coexisting with gastric remnant carcinoma: Case report and review of the literature.

A case of gastric remnant carcinoma coexisting with a chronic afferent loop syndrome harboring multiple enteroliths in a grossly dilated and elongated afferent loop is presented herein. The patient had undergone a Polya type antecolic Billroth II reconstruction for a stenosing duodenal ulcer 40 years previously. A concise review of the relevant literature is also presented.

Acute pancreatitis caused by afferent loop herniation after Billroth II gastrectomy: report of a case and review of the literature.

We present herein the rare case of a 44-year-old man found to have acute pancreatitis due to afferent limb obstruction caused by internal herniation, twelve years after Billroth II gastrectomy. The patient complained of nausea, vomiting, and epigastric pain in acute onset. Physical examination, laboratory studies and computed tomography imaging revealed acute pancreatitis and peritonitis. The patient had been operated on urgently and afferent limb herniation was observed between the afferent loop's meso and duodenum. The herniated segment was incarcerated and the proximal segment of the afferent limb and duodenum were markedly dilated. Microperforations were also observed in the dilated proximal afferent limb. The herniated segment of the bowel was released and longitudinal plication and serosal patching procedure were performed on the afferent limb. The patient recovered after fifteen days and remained free of acute pancreatitis for two years.