Afferent loop syndrome causing recurrent cholangitis and liver abscess

Surgical Rounds®, September 2007, Volume 0, Issue 0

Ramaz E. Metreveli, Attending Surgeon, Department of Surgery, Christiana Care Health Services, Newark, DE; Nicholas J. Petrelli, Medical Director, Helen F. Graham Cancer Center, Department of Surgery, Christiana Care Health Services, Newark, DE

Ramaz E. Metreveli, MD

Attending Surgeon

Department of Surgery

Christiana Care Health Services

Newark, DE

Nicholas J. Petrelli, MD

Medical Director

Helen F. Graham Cancer Center

Department of Surgery

Christiana Care Health Services

Newark, DE

Introduction: Afferent loop syndrome (ALS) is a rare complication of a partial distal gastrectomy that occurs only after Billroth II reconstruction. The condition is difficult to diagnose and requires a high index of suspicion.

Results and discussion: This paper discusses the case of a patient who developed ALS after a Whipple procedure. One of the patient's symptoms was persistent reflux, which resulted in a 100-lb weight loss over a 1-year period despite the administration of total parenteral nutrition during most of that time. The condition was diagnosed based on the findings of an upper gastrointestinal contrast study, and the patient was treated successfully with surgery. The paper also provides a general overview of various disorders that can develop after resection of the stomach as a result of the technique used to re-establish gastrointestinal continuity.

Conclusion: Because ALS rarely occurs following a Whipple procedure, it can be difficult to diagnose. Once ALS has been identified, surgical therapy is necessary to prevent severe complications and consequences.

Afferent loop syndrome (ALS) is a rare complication of a partial distal gastrectomy with Billroth II reconstruction. The condition can be difficult to diagnose and requires a high index of suspicion. We report the case of a patient who developed ALS after a Whipple procedure that was performed for an adenocarcinoma of the head of the pancreas. Following the procedure, the patient suffered recurrent episodes of cholangitis and developed a liver abscess secondary to reflux of contents from the afferent loop to the biliary tract. The degree of reflux observed exceeded what normally would be expected from a biliary jejunal anastomosis. Once the patient's ALS was diagnosed, he was treated successfully with surgery.

Case report

A 57-year-old man had undergone a Whipple procedure 2 years earlier for a T2 N0 M0 adenocarcinoma of the head of the pancreas. Reconstruction was achieved through the sequential placement of pancreatic, biliary, and gastric anastomoses into the same loop of jejunum. The surgery progressed without any complications, and the patient was discharged from the hospital on postoperative day 10, tolerating a regular diet.

Approximately 2 months after the operation, the patient started experiencing dull epigastric abdominal pain, anorexia, and frequent bouts of nausea. His condition progressively worsened, and he began vomiting shortly after each meal. Com?puted tomography (CT) scans of his abdomen did not demonstrate any significant pathology, nor did they show signs of tumor recurrence or metastatic disease.

About 1 year after the Whipple procedure, the patient developed a large abscess in the right lobe of his liver. The abscess was treated using CT-guided percutaneous drainage. Bacteriological analysis of the exudate revealed a mix of aerobic and anaerobic flora consistent with an enteric source. The etiology of the abscess remained unclear, because ultrasonography and magnetic resonance cholangiopancreatography showed no identifiable pathology in the biliary system. Colonoscopy demonstrated diverticulosis, mostly in the left colon, and the liver abscess was attributed to that. The patient was treated with a prolonged course of antibiotics.

The patient's condition continued to deteriorate, and he lost approximately 100 lb over the next year despite being on total parenteral nutrition (TPN) most of the time. The patient also had several bouts of line sepsis with bacteremia and fungemia and one episode of esophageal candidiasis.

When the patient presented to our institution 2 years after the Whipple procedure, he was extremely malnourished compared with his preoperative condition. He reported constant epigastric abdominal pain and nausea with vomiting shortly after each meal. The only remarkable finding on physical examination was slight tenderness in the epigastrium on palpation. There were no signs of sepsis or wound infection.

Laboratory evaluation demonstrated a normal, complete blood cell count and electrolytes, but profound malnutrition was noted, with an albumin of 2.0 g/dL (normal, 3.5 to 5.0 g/dL) and prealbumin of 7.0 mg/dL (normal, 17.0 to 40.0 mg/dL). A subsequent CT scan was unremarkable and showed no signs of tumor recurrence or metastatic disease. Upper intestinal endoscopic evaluation revealed a normal esophagus and proximal stomach, but a large ulcer, measuring about 1.5 cm in diameter, was observed at the site of the gastrojejunal anastomosis. An upper gastrointestinal contrast study with Gastrografin? showed normal passage of contrast through the esophagus and stomach without any significant gastroesophageal reflux. There was, however, severe reflux of contrast into the afferent loop of the gastrojejunostomy (Figure 1). Contrast entered the choledochojejunostomy and filled the entire biliary system. The contrast was noted to move back and forth within the afferent loop, eventually flowing in an antegrade direction down to the small bowel. The degree of opacification of the biliary system with contrast was much more prominent than one would expect after a biliary enteric anastomosis.

Based on these findings, a diagnosis of severe ALS with prominent enterobiliary reflux was made. The patient's previously treated liver abscess was attributed to this reflux. A peptic ulcer at the gastrojejunal anastomosis likely caused the patient's constant epigastric abdominal pain. Because of the patient's profound degree of malnutrition, he was prepared for surgery with a 2-week course of TPN. He tolerated this well, and his nutritional parameters improved significantly, with his albumin and prealbumin increasing to 3.1 g/dL and 24 mg/dL, respectively.

Abdominal exploration found adhesions in the patient's upper abdomen. There was a relatively short distance (less than 1 ft) between the biliary and gastric anastomosis. The gastric remnant was large, and the gastroenteral anastomosis was located in the retrocolic position. The gastrojejunal anastomosis was resected, and a hemigastrectomy with a Roux-en-Y gastrojejunal anastomosis was performed. A bilateral truncal vagotomy was also undertaken. The surgery proceeded uneventfully, and the patient experienced minimal blood loss.

Shortly after surgery, the patient reported complete resolution of the dull epigastric abdominal pain. His bowel function returned to normal several days after the operation, and he started on an oral intake, which he tolerated well. The patient was discharged on postoperative day 7, tolerating a regular diet without any discomfort, nausea, or vomiting. The incision healed by primary intention. At 1-year follow-up, the patient had regained most of his weight, was asymptomatic, and had returned to his prior occupation.

Discussion

Several disorders can develop after resection of the stomach as a result of the technique used to re-establish gastrointestinal continuity (Figure 2). Patients undergoing Billroth II reconstruction are more likely to encounter these problems than those undergoing other types of reconstruction.1 ALS is a rare complication of a partial distal gastrectomy that occurs only after Billroth II reconstruction. It is usually chronic but can be acute in rare cases. The syndrome generally occurs when the afferent limb is longer than 30 to 40 cm and has been anastomosed to the gastric remnant in an antecolic fashion. A variety of factors can contribute to the development of ALS, including kinking and angulation of the afferent limb, internal herniation behind the efferent limb, stenosis of the gastrojejunal anastomosis, redundant twisting of the afferent limb with resultant volvulus, or adhesions involving the afferent limb (Figure 3).

Pancreatic and hepatobiliary secretions occur in response to ingested food entering the gastric remnant or passing into the efferent loop. When the afferent limb is obstructed, these secretions accumulate and cause the limb to distend, which results in epigastric discomfort and cramping. Most patients with ALS have partial obstructions. In this setting, the intraluminal pressure increases and the afferent limb forcefully empties its contents into the stomach, resulting in bilious vomiting that is often projectile but offers immediate relief of symptoms. No food is contained within the vomitus, because the ingested meal has passed into the efferent limb. In the rarer instance of complete obstruction, the obstruction is a closed loop. Necrosis and perforation of the afferent loop can occur because the duodenum was closed proximally during the Billroth II gastrectomy. Constant abdominal pain is generally noted, which may be more pronounced in the right upper quadrant and may radiate to the interscapular area. This condition is a surgical emergency and requires immediate attention.

Whether a patient seeks medical attention depends on the degree of afferent loop obstruction. If the obstruction has been present for a long time, it can be aggravated by the development of blind loop syndrome. When this occurs, there is bacterial overgrowth in the static loop. The bacteria bind with vitamin B12 and deconjugated bile acids, which results in a systemic deficiency of vitamin B12 and development of megaloblastic anemia.2

The acute form of afferent loop ob?struction may occur promptly or many years after a Billroth II gastrectomy. In both circumstances, it is caused by acute blockage of the afferent limb, and volvulus or herniation of the afferent loop posterior to the efferent limb is apparent. If a closed-loop obstruction results, immediate operative intervention is required. A palpable abdominal mass is present in about one third of patients, and the associated pain and tenderness usually are severe enough to indicate the urgent need for operative intervention.

Diagnosing chronic afferent loop obstruction may be more difficult than diagnosing the rarer, acute form of the disorder, even when a patient's symptoms suggest this condition. On occasion, the dilated afferent loop may be seen on plain abdominal radiographs or an obstructed loop may be observed on a contrast barium study of the stomach.3,4 Failure to visualize the afferent limb on upper endoscopy is also suggestive of the diagnosis.

Operation is indicated whether the ALS is acute or chronic, because the condition is a mechanical problem and not a functional one. A long afferent limb is usually the underlying problem; thus, treatment involves the elimination of this loop. Some clinicians have advocated converting the Billroth II construction to a Billroth I anastomosis, whereas others have advocated an enteroenterostomy below the stoma or the use of a Roux-en-Y anastomosis. If a Roux-en-Y anastomosis is performed, a concomitant vagotomy should be done to prevent marginal ulceration from the diversion of duodenal contents from the gastroenteric stoma.

Partial distal gastrectomy was performed more frequently several decades ago, when it was commonly used to treat patients with gastric neoplasms or peptic ulcer disease. Since the incidence of gastric cancer and frequency of elective surgical treatment of peptic ulcer disease have declined significantly, it is performed much less frequently. It is still commonly indicated, however, along with Billroth II reconstruction, as part of a Whipple procedure.

Patients who have undergone the Whipple procedure have a fundamental difference in the anatomical configuration of their organs. Unlike a typical Billroth II reconstruction, which leaves a closed duodenal stump, the Whipple procedure leaves a combination of an afferent loop of small bowel and a biliary-enteric anastomosis. A biliary-enteric anastomosis can be performed multiple ways, depending on its indications. Lateral choledochoduodenostomy is indicated in cases of primary common bile duct stones, common bile duct stones in excess of 10, intrahepatic stones (especially in a patient who has undergone a previous choledochotomy), or if there is a long distal common bile duct stricture due to a primary benign process, such as primary pancreatitis. Endcholedochojejunostomy is performed as part of reconstruction during a Whipple procedure.

All biliary-enteric anastomoses are associated with some degree of enterobiliary reflux unless the bile duct is connected to a Roux-en-Y loop of jejunum. This is because the normal sphincter mechanism of the ampulla of Vater has been eliminated. Peristalsis activity in a long Roux-en-Y loop of small bowel usually functions as an antireflux mechanism. Pneumobilia is a normal radiological finding after a biliary-entero anastomosis. An upper gastrointestinal contrast study in these patients usually demonstrates some degree of opacification of the distal biliary system. The contrast quickly passes through the biliary tree and returns to the bowel. This reflux, however, rarely has clinical significance, probably because the enteric content in these cases is most often sterile.

Conclusion

Our case demonstrates a unique clinical situation that can develop after a Whipple procedure. In this case, an advanced form of ALS led to the development of severe enterobiliary reflux, which had a dramatic clinical manifestation. If a patient's ALS does not result from simple distention of the afferent loop, intraluminal pressure in the afferent loop will significantly increase the likelihood of reflux into the biliary system. Bacterial overgrowth, which is usually present in the afferent loop, can lead to bouts of recurrent cholangitis and sepsis. In our case, the degree of reflux and cholangitis was so severe that the patient developed a liver abscess. Although ALS is extremely rare, it can be difficult to diagnose and could lead to severe consequences if left surgically untreated.

References

  1. Lehnert T, Buhl K. Techniques of reconstruction after total gastrectomy for cancer. Br J Surg. 2004;91(5):528-539.
  2. Townsend C, Mattox KL, Evers BM, et al. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 17th ed. Philadelphia, Pa: Elsevier Health Sciences; 2004:1297-1298.
  3. Woodfield CA, Levine MS. The postoperative stomach. Eur J Radiol. 2005;53(3):341-352.
  4. Kim HC, Han JK, Kim KW, et al. Afferent loop obstruction after gastric cancer surgery: helical CT findings. Abdom Imaging. 2003;28(5):624-630.