Enterolith: an unusual cause of afferent loop obstruction

Management of afferent loop syndrome after Roux-en-Y subtotal gastrectomy and choledocolithiasis with recurrent cholangitis

Afferent loop syndrome is a rare complication after gastrectomy with Billroth II or Roux-en-Y reconstruction, caused by an obstruction in the proximal loop. The biliary stasis and bacterial overgrowth secondary to this obstruction can lead to repeated episodes of acute cholangitis. We present the case of a male patient who had previously undergone gastrectomy with Roux-en-Y reconstruction and later experienced multiple episodes of acute cholangitis secondary to choledocolithiasis. He underwent an open exploration of the bile ducts with choledocolitotomy, but the events of cholangitis persisted. Further investigation permitted to identify a dilation of the biliary loop of the Roux-en-Y anastomosis, suggesting enterobiliary reflux as the cause of recurrent acute cholangitis. Therefore, a bowel enterectomy and new jejunojejunostomy were undertaken, and normal biliary flow was re-established. The surgical treatment is mandatory in benign causes, leading to the resolution of the obstruction and subsequent normalisation of bile flow.

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.

Common Bile Duct Obstruction Due to a Large Stone at the Duodenal Stump

Enterolith is a rare complication of Billroth II gastrectomy. Most enterolith cases have been reported in association with diverticula, tuberculosis, and Crohn's disease. We report the case of a huge enterolith that developed in the duodenal stump following common bile duct obstruction and cholangitis, necessitating surgery. The enterolith was clearly visible on the abdominal computed tomography. It was removed through a duodenotomy. The surgery was successful without any significant complications.

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.

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.

Endoscopic removal of an enterolith causing afferent loop syndrome using electrohydraulic lithotripsy

Electrohydraulic lithotripsy is a very useful method for fragmenting biliary stones and it can be used for endoscopic removal of difficult biliary stones. Acute afferent loop syndrome induced by enterolith is very rare, and surgical treatment is the usual choice for this condition. We describe a patient with acute afferent loop syndrome, which was induced by an enterolith after a Billroth II gastrectomy. We used electrohydraulic lithotripsy to endoscopically remove the enterolith.

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

Enterolith formation is a rare cause of afferent limb obstruction following Billroth II gastrectomy and Roux-en-Y hepaticojejunostomy surgery. A case of ascending cholangitis caused by an enterolith incarcerated in the afferent loop of a 15-year-old Roux-en-Y hepaticojejunostomy was emergently decompressed under direct ultrasound guidance prior to surgery. This is the thirteenth reported case of an enterolith causing afferent loop obstruction. A discussion of our management approach and a review of the relevant literature are presented.

Acute obstruction of the afferent loop caused by an enterolith

Afferent loop obstruction is a relatively rare but significant complication of Billroth II gastrojejunostomy. We report the imaging findings in a patient in whom obstruction presented acutely and was due to the presence of an enterolith. CT showed dilatation of both the main pancreatic duct and the biliary ducts, and a markedly dilated afferent loop within which a 5-cm mass was present. The lesion had a heterogeneous, laminated appearance and did not show any contrast enhancement. Edema of fatty tissues surrounding the pancreatic tail, which extended to the left pararenal spaces, a small amount of free peritoneal fluid surrounding the spleen, and an aneurysm of the splenic artery of about 3 cm were also present. The diagnosis of afferent loop obstruction has to be considered in patients with previous Billroth II gastrojejunostomy who present with acute abdominal pain and laboratory findings indicating pancreatitis. Although rarely, an enterolith can be the cause of obstruction. CT allows to establish the diagnosis.

Biliary stone causing afferent loop syndrome and pancreatitis

We report the case of an 84-year-old female who had a partial gastrectomy with Billroth-II anastomosis 24 years ago for a benign peptic ulcer who now presented an acute pancreatitis secondary to an afferent loop syndrome. The syndrome was caused by a gallstone that migrated through a cholecystoenteric fistula. This is the first description in the literature of a biliary stone causing afferent loop syndrome.

Jejunal Loop Obstruction by a Gallstone from Hepaticojejunostomy-Induced Acute Cholangitis: Report of a Case

We report a case of jejunal loop obstruction by a large gallstone caused by Roux-en-Y hepaticojejunostomy-induced acute cholangitis. The patient was admitted with sepsis as well as abdominal and back pain. Abdominal computed tomography showed a dilated jejunal loop and an obstructing large mass. After his clinical condition and laboratory values improved, we performed laparotomy, which revealed a dilated jejunal loop with a palpable mass, and a gallstone was removed via enterotomy. After the disimpaction of the stone and control of the infection, his clinical condition and laboratory values continued to improve. Gallstone formation is rare after hepaticojejunostomy and to our knowledge, no other cases of acute cholangitis caused by a stone obstructing the jejunal loop have ever been reported. As with other major complications, early diagnosis and prompt initiation of surgical treatment are important to prevent any deterioration in the patient's general condition.

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.

CT of Acute Biliopancreatic Limb Obstruction

OBJECTIVE

Our objective was to report the CT features of biliopancreatic limb (afferent loop) obstruction.

CONCLUSION

Acute biliopancreatic limb obstruction has typical CT features. Given its high morbidity and rate of reoperation, it is useful to make this specific diagnosis instead of reporting the findings as postoperative small bowel obstruction.