Case report

:
B9902011
B9905028
Presented by

HISTORY
 Basic data
Date: 2016-12-30
Chart number: 20180742
Name: OO
Age: 76
Gender: male
Nationality : Taiwan
Occupation: retired
 Chief complaint :
Abdominal fullness with heartburn
sensation for 2 months
 Present illness:
Gastric cancer s/p subtotal gastrectomy with BII
anastomosis in 2013-6
under regular OPD follow up at
the intermittent upper abdominal pain with
general weakness occurred in past 2 months
The food with gastric acid bursted to the mouth
after meal
body weight loss (70kg-65kg in 2 months)
Stool passage was normal
 Past history
Gastric cancer s/p subtotal gastrectomy with
BII anastomosis in 2013-6
Duodenal ulcer perforation s/p op 40 years
ago
History of asthma
 Personal history:
No food or drug allergy history,
smoking(-),alcohol(-), betel nut(-)

Family history:
Denied any systemic disease
 Physical Examination
Vital sign: T:36.4/ P:89/min R:18/min BP:217/99/mmHg
General appearance: Fair looking
Eye: Conjunctiva: not pale; Sclera: not icteric
Neck: Supple, no lymphadenopathy
Chest: Symmetric expansion;
Breathing sound: smooth and clear, no wheezing, no
crackle
Heart: Regular heart beats, no audible murmur, S3, or S4
Abdomen: Flat and soft, no tenderness, no rebounding
pain, normoactive bowel sound
 Lab Data (2016/12/27)
CBC/DC 12-27 12-30 Biochemistry 12-27 12-30

WBC (1000uL) 8.23 8.2 CA19-9 (U/mL) 39.21

RBC (million/uL) 4.79 4.57 CEA (ng/ml) 1.52

Hb (g/dL) 12.0 11.2 AST(U/L) 28

Hct (%) 37.6 35.7 ALT (U/L) 27 218
Plt (1000/uL) 271 220 ALK-P (U/L) 146 266
Seg (%) 63.9 73.0 Total Bilirubin (mg/dL) 0.5 0.7

Lym (%) 24.8 11.6 Lipase(U/L) 650

CRP (mg/dL) 134.2

IMAGE
Image (CT on 12/27)
Image (CT on 12/27)
Image (CT on 12/27)
Image (CT on 12/27)
 Clinical impression
Favor peritoneal carcinomatosis related
Afferent loop syndrome
Gastric cancer s/p subtotal gastrectomy with
BII anastomosis in 2013-6
 Course and treatment
01/02
Operation: Explorative laparotomy with
enterolysis and feeding jejunostomy; excision
biopsy of peritoneal tumor
01/05
Percutaneous drainage of obstructed afferent
loop for decompression of A-loop obstruction
CT image on 1/5
IMAGE
CT image on 1/5
 Course and treatment
1/06
Several vomiting->on NG
Surgical wound pus formation->pus culture,
wet dressing
01/11
transfer to GSICU, NG irrigation
discussed with family about patient`s grave
prognosis and management
 Final diagnosis
Afferent loop syndrome, favor peritoneal
carcinomatosis related
Gastric stump cancer, T4aN1MO, with
peritoneal carcinomatosis
- post subtotal gastrectomy with BII
anastomosis in 201306 and adjuvant
chemotherapy with Xelox for 6 months
Presented by

DISCUSSION
Afferent loop syndrome (ALS)
 Background
Gastrojejunostomy
Anastomosis:stomach and
jejunum
Afferent loop: duodenum and
proximal jejunum
Efferent loop:jejunum distal
to gastrojejunostomy
 Pathophysiology
Complete or partial
Food and gastric
secretions
Secretin and
cholecystokinin
Bile, pancreatic enzymes,
and pancreatic
bicarbonate and water
Up to 1-2 L /day.
 Intraluminal pressure and distention
Postoperative obstructive jaundice, ascending
cholangitis, and pancreatitis
Ischemia and gangrene
perforation and peritonitis.
 Partial obstructionbacterial overgrowth
Bacteria deconjugate bile acids
Steatorrhea
Malnutrition
Vitamin B-12 deficiency
 Etiology
Adhesions
Internal hernia (eg, through a mesocolic defect)
Volvulus
Intussusception
Kinking
Marginal (stomal) ulceration
Recurrence of cancer
Enteroliths
Bezoars
Foreign bodies
Afferent limb syndrome. Kinking of the afferent
limb at the gastrojejunostomy.
 Risk factor
1. Longer than 30-40cm
2. Antecolic position
3. Mesocolic defects
 Epidemiology
Not uncommon
US, approximately 1%
13% of post-pancreaticoduodenectomy
patients.
Decreased in incidence
 Mortality/morbidity
Mortality rates :57%
Bowel infarction or rupture and peritonitis.
Timely diagnosis or chronic manifestations
low morbidity and mortality rates.
 Acute ALS
Complete obstruction of the afferent loop
Right or left upper quadrant abdominal pain
Nausea and vomiting
Vomitus is not bilious
Not decompressed
peritonitis and shock if intestinal perforation
or infarction
 Chronic ALS
Partial obstruction of the afferent loop
Approximately 10-20 minutes to an hour
postprandially
Projectile bilious vomiting
Stasis and bacterial overgrowth
steatorrhea, diarrhea, and vitamin B-12 deficiency
anemia.
bacterial deconjugation of bile salts.
bypassing the duodenum and proximal jejunum, can
result in iron deficiency anemia.
 Physical Examination
1/3 mass in the RUQ with acute ALS.
RUQ or epigastric tenderness
Peritoneal sign
Jaundice
Signs of pancreatitis (eg, upper abdominal
pain radiating to the flank or back
 Laboratory Studies
CBC: anemia (vitamin B-12 deficiency anemia,
iron deficiency anemia),leukocytosis
LFTs:serum bilirubin, ALP, ALT,AST, amylase,
and lipase
Electrolytes:hyponatremia or hypernatremia,
hypokalemia, and hypochloremia. Metabolic
alkalosis may be presentProlonged vomiting
and possible dehydration.
 Carbon 14 xylose breath test
Bacterial overgrowth
Helpful in diagnostic dilemmas and has no role
in acute ALS.
 Plain abdominal radiography
Dilated bowel in the right upper quadrant
No dilated bowel may be present, and a high
clinical suspicion should be maintained in the
appropriate setting
 Upper gastrointestinal series
Nonopacification of the afferent loop on an
upper GI study
Possible delayed filling of an enlarged afferent
loop
 CT
"U-shaped" loop of bowel,
adjacent to the pancreas,
usually containing water
attenuation fluid
possible gallbladder and
biliary dilatation
 Medical Therapy
Acute ALS
Expedient diagnosis and corrective surgery.
Chronic ALS
Preoperative specialized nutritional support or
transfusion before undergoing corrective surgery.
 Surgical Therapy
Interventional radiologic
Billroth I gastroduodenostomy
Roux-en-Y gastrojejunostomy.
Laparoscopic surgery
Percutaneous transhepatic biliary drainage