This is a case of a 71 year-old woman with past medical history of peptic ulcer disease status post Billroth II. She presented with a 3-month history of acute recurrent pancreatitis, postprandial pain, and nausea. Her CT abdomen showed markedly dilated fluid filled proximal jejunum and duodenum. Gallbladder, bile ducts, and pancreatic duct were dilated. Findings are suggestive of afferent loop syndrome. SBFT showed obstruction of the afferent limb in the region of the proximal jejunum with nonopacified duodenum suggesting afferent loop obstruction. Afferent loop syndrome is a rare complication of Billroth II reconstruction. It is a mechanical obstruction of the afferent limb caused by stenosis, ulceration, intussusception or adhesion. Symptoms include postprandial abdominal pain, nausea, vomiting, pancreatitis, and abnormal LFTs
Surgery is usually recommended for acute and chronic obstruction. Non-surgical approaches including internal drainage by stenting and external drainage via percutaneous routes have been proposed. The patient underwent an upper endoscopy for further evaluation and treatment. A Billroth II anatomy was found in the gastric antrum. The anastomosis was patent. The afferent limb was entered. We noted a very a tight stricture with tiny opening. The inner diameter was approximately 1 mm. We were unable to advance the scope beyond this point. Using an autotome catheter, a .035 inch stiff FX wire was passed easily through the opening. We noted bile flowed through the opening as the wire was being advanced. Fluoroscopic images confirmed the location of the wire. Over the wire, the autotome catheter was advanced into the opening. Contrast was injected. The contrast appeared to stay in the lumen, which was massively dilated. The wire was then advanced deeply into the lumen under fluoroscopy. The stricture was successfully dilated with an 8 mm esophageal balloon dilator. The location of the balloon and the wire was confirmed under fluoroscopy. The pressure was held for 1 minute. We noted mild resistance. Bile and secretion were noted after removal of the balloon catheter. Repeat dilation was performed with a 10 mm balloon dilator. Fluoroscopic image confirmed the location of the wire and the balloon. A large amount of bile and fluid flowed through the stricture after dilation. Minimal amount of blood was noted. The patient did well after the procedure. Her symptoms improved significantly. She returned two weeks later for further therapy. Underfluoroscopy, we repeated dilation with a 10 mm biliary dilator balloon over a .035 Jagwire. After dilation, we successfully traverse the stricture with a 27 Fr gastroscope. A dilated small intestine was seen. Fluoroscopic image showed that the scope was in the right upper quadrant corresponding to the blind ending of the duodenum. The major papilla was identified. We repeated dilation with a 15 mm pyloric balloon. A significant improvement of the stricture was noted.
In summary, we presented a case of acute recurrent pancreatitis caused by afferent loop syndrome. Successful endoscopic dilation of the afferent limb stenosis was performed underfluoroscopy. The patient had no episodes of recurrent pancreatitis. The diagnosis of afferent loop syndrome requires a high index of suspicion in the right clinical setting. Endoscopic balloon dilation of the stenotic site can be considered as a treatment option.
Nonthalee Pausawasdi, MD,