Acute cholangitis due to afferent loop syndrome after a Whipple procedure: a case report

Abstract

IntroductionPatients with resection of stomach and especially with Billroth II reconstruction (gastro jejunal anastomosis), are more likely to develop afferent loop syndrome which is a rare complication. When the afferent part is obstructed, biliary and pancreatic secretions accumulate and cause the distention of this part. In the case of a complete obstruction (rare), there is a high risk developing necrosis and perforation. This complication has been reported once in the literature.Case presentationA 54-year-old Greek male had undergone a pancreato-duodenectomy (Whipple procedure) one year earlier due to a pancreatic adenocarcinoma. Approximately 10 months after the initial operation, the patient started having episodes of cholangitis (fever, jaundice) and abdominal pain. This condition progressively worsened and the suspicion of local recurrence or stenosis of the biliary-jejunal anastomosis was discussed. A few days before his admission the patient developed signs of septic cholangitis.ConclusionOur case demonstrates a rare complication with serious clinical manifestation of the afferent loop syndrome. This advanced form of afferent loop syndrome led to the development of huge enterobiliary reflux, which had a serious clinical manifestation as cholangitis and systemic sepsis, due to bacterial overgrowth, which usually present in the afferent loop. The diagnosis is difficult and the interventional radiology gives all the details to support the therapeutic decision making. A variety of factors can contribute to its development including adhesions, kinking and angulation of the loop, stenosis of gastro-jejunal anastomosis and internal herniation. In order to decompress the afferent loop dilatation due to adhesions, a lateral-lateral jejunal anastomosis was performed between the afferent loop and a small bowel loop.

Recurrent ascending cholangitis due to small intestinal bacterial overgrowth, gastrointestinal dysmotility and an afferent loop

“…A few case reports describe single episodes of ascending cholangitis, post-Whipple procedure, in the presence of an obstructed afferent loop (afferent loop syndrome) 13. However, to the best of our knowledge, ours is the only case reporting recurrent ascending cholangitis causing sepsis in the absence of mechanical obstruction of the afferent loop.…”

“…This occurs when the open end is occluded, with resultant accumulation of biliary and pancreatic secretions and increase in intraluminal pressure. Thus, reflux of secretions in biliary and pancreatic ducts may occur to produce cholangitis or pancreatitis, respectively 13 14. Sonographically, an obstructed loop may be evident as a dilated loop lying across the midline 15.…”

Acute afferent loop necrosis after Roux-en-Y cholangiojejunostomy

“…Acute afferent loop necrosis is a rare sequela of Roux-en-Y reconstruction [1][2][3][4][5]. In our case, the peripheral part of the Roux-en-Y limb, including the cholangiojejunostomy portion, was twisted just proximal to the cholangiojejunostomy.…”

“…Usually, afferent loop obstruction is a chronic complication, and its diagnosis is difficult [4,[6][7][8][9]. Along with imaging techniques such as CT and ultrasonography, clinical history has been reported to aid in preoperative diagnosis of acute afferent loop necrosis [6,7,10].…”

“…Afferent loop syndrome is a rare complication after Rouxen-Y reconstruction [1][2][3][4][5]. We report the case of a patient who developed acute necrotic afferent loop obstruction, 8 months after Roux-en-Y cholangiojejunostomy.…”