Blind Pouch Syndrome-associated Anastomotic Ulcer Diagnosed with Capsule and Double-balloon Endoscopy

Blind pouch syndrome-associated anastomotic ulcer is rare, and its endoscopic features remain poorly described. A 79-year-old man was referred to our hospital for melena. Capsule endoscopy revealed multiple ulcers in the small intestine. Double-balloon endoscopy (DBE) and a gastrografin examination through DBE revealed a potential anastomotic ulcer, a blind pouch, and a side-to-side anastomosis in the middle of the small intestine. Laparoscopic partial resection of the small intestine with anastomosis was performed on the suspected blind pouch syndrome-associated anastomotic ulcer. To our knowledge, this is the first report describing the endoscopic features of a blind pouch syndrome-associated anastomotic ulcer.

Blind Pouch Syndrome in Gastrojejunostomy

Blind pouch syndrome is a rare complication of a gastrojejunostomy. Its presentation may differ from blind pouches at other locations in that a small pouch can cause significant symptoms of mechanical obstruction before it is large enough to develop bacterial overgrowth. The effect of a small pouch may be overlooked at endoscopy and a high clinical index of suspicion is required. Here we present a case report of Gastrojejunostomy Blind Pouch Syndrome to highlight this clinically distinct entity.

[Blind loop syndrome]

Malabsorption can raise from several causes, including post surgical conditions. Noticeably, ileo-ileal anastomosis can lead to bacterial stagnation in the caecum, with recirculation of the intestinal content, and intestinal spreading of the colonic flora. We review here nine cases who were operated on in our department in the last 20 years. In five patients the syndrome appeared after an intestinal resection due to a postsurgical intestinal infarction due to adhesions. In four patients it appeared after an ileo-transverse derivation motivated by post-surgical occlusion. We conclude that any type of malabsorption appearing after abdominal surgery, even remotely from the surgical procedure should suggest this uncommon diagnosis. Surgical treatment, i.e. replacement of the intestinal anastomosis with a new termino-terminal anastomosis, is necessary and sufficient.

Laparoscopic surgery for blind pouch syndrome following Roux-en Y gastrojejunostomy: report of a case

We report herein the case of a 59-year-old man in whom blind pouch syndrome was successfully treated by laparoscopic surgery. The patient had undergone distal gastrectomy and Roux-en Y gastrojejunostomy for a peptic ulcer 35 years previously, and had been suffering from watery diarrhea, anemia, weight loss, and pain in the left upper quadrant of his abdomen for several years. Long-term insufficient oral intake and the malabsorption of nutrients had resulted in severe emaciation. Gastrointestinal contrast study revealed a large blind pouch, 30 x 23cm in diameter, draining into the gastrojejunostomy. Laparoscopic resection of the blind pouch was performed. Despite the presence of dense intraabdominal adhesions, we identified the blind pouch with the help of tattoo marks that had been made at the neck of the pouch preoperatively. After thoroughly dissecting the adhesions around the pouch, we resected the pouch at the neck. The patient had an uneventful postoperative course. This case report demonstrates that large blind pouches such as this may be effectively treated using laparoscopic surgery.

[Microbial overgrowth syndrome after gastrectomy. Recent diagnostic aspects]

Blind loop syndrome is the most common syndrome of bacterial overgrowth following gastrectomy. We report two cases with diarrhea, steatorrhea, exudative enteropathy and major nutritional deficiency. Diagnosis was based on the breath test and aspirate analysis. Surgery with restoration of the duodenal continuity was the treatment. Patients with contraindications for surgery should be given prolonged antibiotic therapy which should be repeated if symptoms reoccur.

[Blind loop of the large intestine--bypass enteropathy or diversion colitis?]

Investigating three patients with longstanding diarrhoea, severe abdominal bloating and cramps revealed an exclusion of the right hemicolon in all patients and additionally of the terminal ileum in one of them. The anastomosis of the ileo-colic bypass, performed decades ago due to complicated appendicitis, was stenotic in two of them. Because a classical blind-loop-syndrome could not be proven, the functional disorder is described as a clinical entity characterized by signs of bypass-enteropathy and diversion-colitis. The importance of the radiological examination for diagnosis and therapy-planing is emphasized, because endoscopically and histologically Crohn's disease might be suspected. The surgical reintegration of the bowel into the orthograde continuity of the intestinal tract is recommended as the causative treatment. Symptoms disappear completely and patients win normal health even after some decades, because the morphological signs of inflammation are reversible and bowel function is not lost during the exclusion.

[Two cases of blind pouch syndrome]

Case 1. A 39-yr-old male was presented with anemia. Initial blood examination showed remarkable iron deficiency anemia. Small bowel X-ray and abdominal CT examination revealed a dilated tract at the end of the ileum. Surgical operation was done. The surgical specimen showed side to side anastomosis which was reconstructed at the operation for rt. inguinal herniation 46 days after his birth. The oral side of the tract was remarkably dilated. Case 2. A 50-yr-old male was presented with dizziness. He had anemia and clubbed fingers. A small bowel X-ray examination was done and it showed side to side anastomosis in the middle of the small intestine. Surgical operation was performed. The surgical specimen showed side to side anastomosis about 2 m 20 cm from the Treitz' ligament, which was reconstructed during the operation for ileus when he was 10 years old. The blind portion was remarkably dilated. In both case, the anemia was improved after the operation.

Cure of arthritis-dermatitis syndrome due to intestinal bypass by resection of nonfunctional segment of blind loop

Many complications that followed jejunoileal bypass operations performed for the relief of morbid obesity were caused by bacterial overgrowth in the excluded blind loop. The arthritis-dermatitis syndrome was one of the common distressing disorders. The pathogenetic mechanism was thought to be an immune-complex-mediated process related to bypass enteritis. Antiarthritic medication was ineffective in most instances, and the skin lesions were refractory to treatment. A 45-year-old woman was suffering from the disorder as described above. She also had diarrhea, a low hematocrit, an elevated white blood cell count, and an increased sedimentation rate. Her nutritional status was satisfactory, presumably because of adaptive hypertrophy of the short functioning small intestinal segment. The patient adamantly refused dismantling of the bypass or any gastric restriction operations. Therefore, the blind loop, the source of her disease, was excised with immediate relief of all ill effects and restoration of normal laboratory findings. The patient has been entirely well since, and her weight has remained stable for one year.

Multiple malignant lymphoma within an ileal blind loop--report of a case

A 55-year-old woman presented to our hospital with abdominal fullness and edema of both legs. She had undergone a bypass operation by an ileotransversostomy for adhesive ileus following a drainage operation for acute appendicitis 35 years previously. We diagnosed the patient as having blind loop syndrome as a consequence of the side-to-side ileotransversostomy, and performed a right hemicolectomy and intestinal resection. The resected specimen of dilated ileal blind loop contained 15 crater-like lesions, proven histologically to be nodular proliferation of atypical lymphocytes. Lymph follicles had also proliferated in the mucosa of the blind loop and the histologically confirmed diagnosis of non-Hodgkins lymphoma of the diffuse medium-sized cell type was thus made. The etiology of such tumors is probably related to the alteration in intestinal environment caused by conditions such as fecal stasis, bacterial overgrowth, and bacterial toxins in the blind loop.

Ischemic jejunal stenosis and blind loop syndrome after blunt abdominal trauma

One month after suffering blunt abdominal trauma a patient developed severe steatorrhea and profound weight loss in association with an ischemic distal jejunal stricture and blind loop syndrome. Evidence for a partial mesenteric tear was found at resection of the stricture, which resulted in complete cure.

Technical complications of Roux-en-Y gastrojejunostomy

The Roux-en-Y gastrojejunostomy has become an increasingly popular technique for gastrointestinal tract reconstruction since it is purported to obviate many of the classic complications of the Billroth II gastrojejunostomy. In a review of over 900 Roux-en-Y gastrojejunostomies, seven patients with complications mimicking those seen with Billroth II reconstruction were identified. These complications included duodenal stump blowout, proximal blind loop or afferent loop syndrome, and bile-reflux gastritis. These complications resulted from technical problems in construction of the Roux-en-Y. Once the complications were diagnosed, they were amenable to operative correction. Recognition of the potential for these complications following Roux-en-Y gastrojejunostomy should aid in early diagnosis and treatment.

The intestinal bypass: arthritis-dermatitis syndrome

Of the 31 patients who developed polyarthritis following jejunoileal bypass for obesity, 24 had cutaneous vasculitis (urticarial, pustular, and nodular), 11 paresthesias, 10 Raynaud's phenomenon, and 1 pericarditis. Blind loop symptoms (14 of 26 patients), cryoglobulinemia (10 of 28), and immune deposits in biopsied skin lesions (5 of 7) support the theory of a relationship between bowel bacteria and immune complexes. Treating the blind loop with antibiotics and sphincteroplasty to prevent bacterial reflux into the blind loop helped 5 of 10 and 6 of 9 patients, respectively. A comparison is made to other bowel associated arthritides.

Ileostomy of the distal end of the bypassed intestine in a patient with jejunoileal bypass for obesity

Ileostomy of the distal end of the bypassed segment of small intestine was done twenty-three months after a 28 to 20 cm (12 to 8 inch) end-to-end jejunoileal bypass for obesity (Scott operation) in a forty-eight year old white female, thus creating a Thiry fistula. Weight prior to jejunoileal bypass was 130 kg (287 pounds). Before ileostomy it had stabilized at 80.3 kg (177 pounds). Indications for ileostomy were three episodes of blind loop syndrome and three episodes of severe bleeding from the ileotransverse colostomy anastomotic site. Culture of the bypassed segment at laparotomy revealed bacteroides, clostridia, and other anaerobes as well as the usual aerobic large bowel flora. After ileostomy the bypassed segment contained no anaerobic bacteria. Daily fluid output from the ileostomy has decreased with time, averaging 436 ml per day for the first postileostomy month and 50 ml per day for the ninth month. Beneficial effects of the ileostomy include: (1) better sense of well being; (2) no further episodes of blind loop syndrome or intestinal bleeding; and (3) cessation of anal itching. Nine months after ileostomy, hyperoxaluria and acquired megacolon were present. Weight was 5.9 kg (13 pounds) greater than before ileostomy.

[Intestinal hemorrhage due to blind loops. 3 cases and review of the literature]

The authors report 3 cases of intestinal bleeding either micro- or macroscopic induced by ulcers in blind loops. The blind loops developed in all 3 cases on side-to-side ileocolic anastomoses. In one of the patients, the ulcers were demonstrated by colonoscopy. The 3 cases reported are quite comparable to the 18 cases found in the world literature. These hemorrhages may become severe by their abundance or repetition, but a cure is easily obtained by resection of the intestinal blind loops and restoration of the continuity by end-to-end anastomosis.

[The blind-loop syndrome after side-to-side anastomoses of the gut (author's transl)]

The postoperative blind-loop syndrome can occur after side-to-side, end-to side or by-pass anastomoses of the gut and presents clinically as malabsorption syndrome. Pathogenetically, stasis or slowing of the bowel movements will cause a rapid increase of pathogenic bacteria in the small intestine. Malabsorption is characterized by 3 symptoms: Loss of weight, anemia, steatorrhoea. The method of choice for therapy is to perform a new, end-to-end, anastomosis of the intestine in order to re-establish a physiological situation. During the last 6 years 14 patients with malabsorption syndromes of varying degrees were operated upon: 6 had pure small intestinal anastomoses, 7 anastomoses between the small and large intestine and 1 patient had a side-to-side sigmoidal anastomosis. In all patients the side-to-side or by-pass anastomoses could be reversed.

Stagnant loop syndrome with evidence of bile salt deconjugation in a child

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