Afferent loop syndrome presenting as enterolith after Billroth II subtotal gastrectomy: a case report

Abstract

We present a rare late-onset (after 24 years) complication of gastric surgery with a combination of afferent loop syndrome associated with a large duodenal stone. The patient, who had undergone Billroth II partial gastrectomy for benign ulcer 24 years before, developed abdominal pain in the right upper quadrant, associated with nausea, vomiting, and high grade fever. Abnormal laboratory values included elevated liver function test, suggesting a pressure-related phenomenon. Leukocytosis and a high level of platelets were also found. Only computed tomography and endoscopy of the upper gastrointestinal tract confirmed the diagnosis of a huge stone in the dilated duodenal afferent loop. To our knowledge, a case like this has not been reported previously in the literature.

Enterolith causing acute afferent loop syndrome after Billroth II gastrectomy: a case report

“…It usually develops within the first week after surgery, mainly due to retrograde intussusception, technical error in constructing the gastrojejunostomy, or kinking or edema at the anastomotic site (7). Rarely, as in our case, this syndrome occurs many years after surgery and also in relation to an enterolith (3,4). Most of the enteroliths have been reported in association with diverticula of the small intestine, Crohn's disease or tuberculosis of the small bowel (3).…”

“…In these cases, through the drainage catheter, it is possible a radiological study of the afferent loop and the percutaneus removal of the enterolith (2). The endoscopic extraction is difficult (1,3,20) and may lead to perforation (20). Using electrohydraulic lithotripsy endoscopic removal of the enterolith is feasible (6).…”

True Primary Enterolith Treated by Balloon-assisted Enteroscopy

“…It is assumed that the formation of true primary enteroliths is related to intestinal stricture and stenosis due to Crohn's disease, radiation enteritis or intestinal tuberculosis (2). In addition, bowel hypomotility or stasis, due to the existence of Meckel's diverticulum or afferent loops after surgery, may cause the formation of true primary enteroliths (2,(7)(8)(9). Under these conditions, intestinal bacterial overgrowth can readily occur, resulting in the promotion of bile salt deconjugation (10).…”

Electrohydraulic Lithotripsy of an Impacted Enterolith Causing Acute Afferent Loop Syndrome

“…Enteroliths are stones that develop within the intestinal tract. Most enteroliths are usually encountered within diverticula, surgically created intestinal pouches or proximal to an obstruction in the small or large bowel 5. Enterolith formation is thought to be attributable to bowel hypomotility or stasis.…”