Enterolith causing afferent loop obstruction: a case report and literature review

Afferent loop obstruction induced by undigested food (phytobezoar) treated through endoscopic fragmentation with biopsy forceps: A case report

INTRODUCTION AND IMPORTANCE

Afferent loop obstruction (ALO) can occur as a complication of gastrectomy with Billroth II or Roux-en-Y reconstruction. Conventionally, emergent surgery was performed for most cases, while endoscopic procedures for elective cases have been reported more recently. We report a unique case of ALO caused by a phytobezoar that was successfully treated by endoscopic procedures.

CASE PRESENTATION

A 76-year-old female patient presented with epigastric pain for several hours after dinner. The patient had a history of distal gastrectomy with Roux-Y reconstruction for gastric cancer at age 62. Computed tomography (CT) demonstrated evident dilation of the duodenum and common bile duct, and detected a bezoar at the jejunojujunal anastomosis site, indicating that the ALO was induced by the bezoar. Upper endoscopy visualized undigested food formation stuck at the anastomosis site, and it was successfully dislodged by endoscopic fragmentation using biopsy forceps. After the procedure, the abdominal symptoms subsided, and the patient was discharged on the fourth day.

CLINICAL DISCUSSION

Bezoar-induced ALO is rare. In this case, CT helped diagnose the ALO induced by the bezoar. In recent times, there has been a rise in endoscopic interventions for ALO, and there are some reports of bezoar-induced small bowel obstruction being treated endoscopically. Therefore, a subsequent endoscopic examination was performed, confirming the presence of a phytobezoar and leading to a less invasive endoscopic fragmentation treatment in this case.

CONCLUSION

This is a unique case report of phytobezoar-induced ALO treated by endoscopic fragmentation of undigested food, providing a beneficial treatment option.

Enterolith Causing Afferent Loop Perforation After Distal Gastrectomy

Afferent loop syndrome is a complication that occurs after the Billroth Ⅱ reconstruction or Roux-en-Y reconstruction and can also be caused by enteroliths. We experienced a case of duodenal perforation due to afferent loop syndrome caused by an enterolith, in which surgical removal of the enterolith and decompression of the duodenum were effective. A 73-year-old female who underwent distal gastrectomy and Roux-en-Y reconstruction for gastric cancer 14 years ago came to the hospital with acute abdominal pain and underwent emergency surgery for afferent loop syndrome and duodenal perforation due to enterolith. The patient underwent removal of the enterolith, drain placement, and placement of a decompression tube in the duodenum. Postoperatively, percutaneous drainage of the intra-abdominal abscess was necessary, but the patient was saved without reoperation. Afferent loop perforation may occur with obstruction due to enteroliths, and the surgical insertion of a tube to decompress the afferent loop is effective.

Primary Jejunal Enterolith Causing Small Bowel Obstruction Without Any Underlying Bowel Abnormality

Enterolith formation is a rare condition precipitated by decreased bowel motility. It may cause obstruction or other complications and the diagnosis usually is confirmed after surgery and analysis of the stones or fragments. It is often seen in association with intestinal abnormalities such as diverticula and inflammation or in biliary tract fistulas where stones migrate to the duodenum and small bowel. We report an unusual case of a primary true enterolith formation in a patient without any underlying bowel condition or any previous surgery.

Enterolith in Roux limb causing extrahepatic biliary obstruction in a patient with a hepaticojejunostomy: case report and relevant literature review

Enterolith in the Roux limb of hepaticojejunostomy causing jaundice is a rare occurrence. A 40-year-old woman had an extrahepatic biliary obstruction and cholangitis 13 years after the Roux-en-Y repair of postcholecystectomy benign biliary stricture. On evaluation, an enterolith was obstructing the Roux limb, which was successfully managed surgically.

Afferent Loop Syndrome with Intestinal Ischemia due to Internal Hernia after Whipple Operation for T2N1M0 Pancreatic Cancer

Afferent loop syndrome is an uncommon complication of Whipple procedure. The often vague and non-specific presentation results in difficulty and/or delay in diagnosis, which may lead to bowel ischemia or perforation. CT can demonstrate characteristic features, yield the diagnosis of afferent loop syndrome, and predict the cause before surgical intervention. We present a rare etiology of acute afferent loop syndrome in a patient 6 weeks after Whipple procedure who was reportedly recovering well, which resulted in prompt surgical intervention.

Diagnosis and treatment of the afferent loop syndrome

Afferent loop syndrome (ALS) is a mechanical complication that arises after gastric surgery with gastrojejunostomy reconstruction. This condition was first described in 1950 by Roux, Pedoussaut, and Marchal to post-gastrectomy patients with bilious vomiting. Acute ALS is associated with complete obstruction and considered a surgical emergency, whereas chronic ALS is mostly related to partial obstruction of the afferent loop. The delay in diagnosis may lead to intestinal ischemia, perforation and can be associated with a high mortality rate up to 60%. Surgery is usually the mainstay treatment of ALS, but endoscopic therapy, including stent placement in malignancy-related, anastomotic stricture dilation, has been evolving over the past recent years.

Bile Salt Enterolith: An Unusual Etiology Mimicking Gallstone Ileus

Primary enterolithiasis is a relatively uncommon but important cause of small bowel obstruction. We present a case of a 69-year-old male with a history of laparoscopic Roux-en-Y gastric bypass and asymptomatic duodenal diverticulum diagnosed with small bowel obstruction. CT imaging showed an obstruction distal to the jejunojejunostomy, and surgical intervention was warranted. A 4.5 cm enterolith removed from the distal jejunum was found to contain 100% bile salts, consistent with a primary enterolith. Clinicians should retain a high index of suspicion for enteroliths as a cause of small bowel obstruction, especially if multiple risk factors for enterolith formation are present.

Afferent loop obstruction with obstructive jaundice and ileus due to an enterolith after distal gastrectomy: A case report

INTRODUCTION

Afferent loop obstruction is an uncommon complication associated with Billroth II reconstruction or Roux-en-Y reconstruction after gastrectomy. Moreover, cases where the obstruction is caused by enterolith are rare. Here, we report a rare case of afferent loop obstruction caused by an enterolith after Roux-en-Y reconstruction of gastrectomy; subsequently, leading to ileus in the ileum.

PRESENTATION OF CASE

An 84-year-old man who received a Roux-en-Y distal gastrectomy for gastric cancer presented with symptoms of fever and jaundice 14 months later. Computed tomography (CT) scan revealed an enterolith in the duodenal afferent loop and a dilated intrahepatic bile duct. Although the obstructive jaundice and fever disappeared with conservative therapy, ileus occurred due to the movement of the enterolith into the ileum, which was refractory to conservative therapy. Therefore, enterotomy was performed to remove the enterolith, and the patient had an uneventful recovery. Histologically, the enterolith derived from food residue. No postsurgical sign of recurrence has been noted for 6 months.

CONCLUSION

We report a rare case where an enterolith in a duodenal afferent loop after distal gastrectomy led to obstructive jaundice, and subsequently, caused ileus by its movement into the ileum.

Roux-en-Y enterolith leading to obstruction and ischemic necrosis after pediatric orthotopic liver transplantation

Biliary complications are a common cause of morbidity after liver transplantation, with biliary stone formation being a known occurrence generally upstream of a stricture. A 12-year-old boy, who underwent an orthotopic liver transplantation at 11 months of age for biliary atresia, presented acutely with fever and abdominal pain. Cross-sectional imaging revealed Roux-en-Y limb dilatation and thickening. He was explored and was found to have an ischemic Roux limb secondary to an obstructing enterolith. A segmental bowel resection and revision of his hepaticojejunostomy was performed. While rare, biliary enteroliths may present as either a bowel obstruction or cholangitis and should be considered in the differential diagnosis of a patient following biliary reconstruction. Additionally, anatomic etiologies should be considered and potentially surgically corrected.

Acute afferent loop syndrome in the early postoperative period following pancreaticoduodenectomy

INTRODUCTION

Afferent loop syndrome (ALS) is a recognised complication of foregut surgery caused by mechanical obstruction at the gastrojejunostomy anastomosis itself or at a point nearby. Acute ALS has only been reported following pancreaticoduodenectomy (PD) after several years due to recurrence of malignancy at the anastomotic site. We report five cases of acute ALS in the first postoperative week.

METHODS

The presentation, clinical findings and successful management of the 5 patients with ALS were obtained from a prospectively collected database of 300 PDs. All five patients with early acute ALS presented with signs and symptoms of a bile leak. Since the fifth patient, the surgical technique has been modified with the creation of a larger window in the transverse mesocolon and a Braun enteroenterostomy.

RESULTS

There have been no further incidents of ALS since the adoption of these modifications to the standard technique of PD and there has also been a reduction in postoperative bile leaks (6.4% vs 3.6%, p=0.416).

CONCLUSIONS

Acute ALS is a rare but important complication in the immediate postoperative period following PD and causes disruption to adjacent anastomoses, resulting in a bile leak. A prophylactic Braun anastomosis and wide mesocolic window may prevent this complication and subsequent deterioration.

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.

Management of afferent loop obstruction: Reoperation or endoscopic and percutaneous interventions?

Afferent loop obstruction is a purely mechanical complication that infrequently occurs following construction of a gastrojejunostomy. The operations most commonly associated with this complication are gastrectomy with Billroth II or Roux-en-Y reconstruction, and pancreaticoduodenectomy with conventional loop or Roux-en-Y reconstruction. Etiology of afferent loop obstruction includes: (1) entrapment, compression and kinking by postoperative adhesions; (2) internal herniation, volvulus and intussusception; (3) stenosis due to ulceration at the gastrojejunostomy site and radiation enteritis of the afferent loop; (4) cancer recurrence; and (5) enteroliths, bezoars and foreign bodies. Acute afferent loop obstruction is associated with complete obstruction of the afferent loop and represents a surgical emergency, whereas chronic afferent loop obstruction is associated with partial obstruction. Abdominal multiple detector computed tomography is the diagnostic study of choice. CT appearance of the obstructed afferent loop consists of a C-shaped, fluid-filled tubular mass located in the midline between the abdominal aorta and the superior mesenteric artery with valvulae conniventes projecting into the lumen. The cornerstone of treatment is surgery. Surgery includes: (1) adhesiolysis and reconstruction for benign causes; and (2) by-pass or excision and reconstruction for malignant causes. However, endoscopic enteral stenting, transhepatic percutaneous enteral stenting and direct percutaneous tube enterostomy have the principal role in management of malignant and radiation-induced obstruction. Nevertheless, considerable limitations exist as a former Roux-en-Y reconstruction limits endoscopic access to the afferent loop and percutaneous approaches for enteral stenting and tube enterostomy have only been reported in the literature as isolated cases.

True Primary Enterolith Treated by Balloon-assisted Enteroscopy

Primary enterolith is a rare condition that can induce ileus and intestinal perforation. We report the first case of a true primary enterolith treated by balloon-assisted enteroscopy. The patient presented with a small intestinal ileus. After its improvement following the insertion of an ileus tube, radiography with amidotrizoate sodium meglumine detected a round, movable defect in the ileum measuring 42 mm diameter. The patient was diagnosed with a primary enterolith based on her past history. The enterolith was fractured and removed using balloon-assisted enteroscopy. This case suggests that balloon-assisted enteroscopy may be an effective non-invasive treatment option for enteroliths.

Enterolithiasis

Enterolithiasis or formation of gastrointestinal concretions is an uncommon medical condition that develops in the setting of intestinal stasis in the presence of the intestinal diverticula, surgical enteroanastomoses, blind pouches, afferent loops, incarcerated hernias, small intestinal tumors, intestinal kinking from intra-abdominal adhesions, and stenosing or stricturing Crohn’s disease and intestinal tuberculosis. Enterolithiasis is classified into primary and secondary types. Its prevalence ranges from 0.3% to 10% in selected populations. Proximal primary enteroliths are composed of choleic acid salts and distal enteroliths are calcified. Clinical presentation includes abdominal pains, distention, nausea, and vomiting of occasionally sudden but often fluctuating subacute nature which occurs as a result of the enterolith tumbling through the bowel lumen. Thorough history and physical exam coupled with radiologic imaging helps establish a diagnosis in a patient at risk. Complications include bowel obstruction, direct pressure injury to the intestinal mucosa, intestinal gangrene, intussusceptions, afferent loop syndrome, diverticulitis, iron deficiency anemia, gastrointestinal hemorrhage, and perforation. Mortality of primary enterolithiasis may reach 3% and secondary enterolithiasis 8%. Risk factors include poorly conditioned patients with significant obstruction and delay in diagnosis. Treatment relies on timely recognition of the disease and endoscopic or surgical intervention. With advents in new technology, improved outcome is expected for patients with enterolithiasis.

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.

Enterolith causing acute afferent loop syndrome after Billroth II gastrectomy: a case report

Enterolith is a rare cause of afferent loop obstruction following Billroth II gastrectomy. We report a case of acute afferent loop syndrome (ALS) due to a huge enterolith, necessitating prompt surgery. The clinical pattern may mimic acute cholangitis and/or pancreatitis. Delayed diagnosis may result in severe complications such as bowel ischemia or perforation. Only 14 reported cases of enterolith causing afferent loop obstruction were found in the English literature.

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.

Recurrent ascending cholangitis due to small intestinal bacterial overgrowth, gastrointestinal dysmotility and an afferent loop

We report a complex case involving an extremely rare cause of gastrointestinal dysmotility and an afferent loop, which together predisposed to the development of small intestinal bacterial overgrowth. The bacteria subsequently became multi-resistant. As a further consequence of the dysmotility, repeated bile duct reflux occurred despite the afferent loop being unobstructed. This bile duct reflux produced recurrent sepsis through repeated episodes of ascending cholangitis. Ultimately, the patient was referred to a National Small Intestinal Transplant Centre for consideration for enterectomy and subsequent transplantation. We describe the difficulties encountered in managing this unique case and discuss the underlying aetiology.