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Recurrent Acute Pancreatitis Caused by Afferent Loop Stricture After Gastrectomy

Recurrent Acute Pancreatitis Caused by Afferent Loop Stricture After Gastrectomy Abstract Afferent loop obstruction after gastrectomy and Billroth II gastrojejunostomy is only rarely diagnosed as the cause of recurrent acute pancreatitis. Three patients are described in whom afferent loop stricture after gastrectomy and Billroth II reconstruction manifested as recurrent pancreatitis 13 to 24 years after the initial procedure. Late onset, nonspecific symptoms, and other simultaneous gastrointestinal pathologic features promoted a chronic clinical course in all patients. Symptoms included acute abdominal pain, vomiting, jaundice, hyperamylasemia, weight loss, and anemia. A thorough history, barium examination, cholescintigraphy, and endoscopy were central in establishing the diagnosis. The pathogenesis of stricture formation is thought to be ischemic mucosal damage from intestinal crossclamping. Surgical decompression provided lasting relief of the symptoms. Afferent loop stricture should be considered in the differential diagnosis in patients with recurrent acute pancreatitis and previous gastrectomy with Billroth II reconstruction. (Arch Surg. 1995;131:561-565) References 1. Hinshaw DB, Carter R, Baker HW, Wise RA. Postgastrectomy afferent loop obstruction simulating acute pancreatitis . Ann Surg . 1960;151:600-604.Crossref 2. McMaster P, Wjietjunge DB. Postgastrectomy afferent loop obstruction due to efferent loop herniation simulating acute pancreatitis . Br J Surg . 1976;63:526-527.Crossref 3. Everett WG, Sampson D. Afferent loop obstruction mimicking acute pancreatitis . Br J Surg . 1969;56:843-844.Crossref 4. Conter RL, Converse JO, McGarrity TJ, Koch KL. Afferent loop obstruction presenting as acute pancreatitis and pseudocyst: case reports and review of the literature . Surgery . 1990;108:22-27. 5. Dahlgren S. The afferent loop syndrome . Acta Chir Scand . 1964;327:1-149. 6. Bushkin FL, Woodward ER. The afferent loop syndrome . Maj Probl Clin Surg . 1976;20:34-48. 7. Woodward ER. The pathophysiology of afferent loop syndrome . Surg Clin North Am . 1966;46:411-423. 8. Eagon JC, Miedema BW, Kelly KA. Postgastrectomy syndromes . Surg Clin North Am . 1992;72:445-462. 9. Hoffman WA, Spiro HM. Afferent loop problems . Gastroenterology . 1961;40: 201-209. 10. King PM, Bird DR, Eremin O. Enterolith obstruction of the small bowel . J R Coll Surg Edinb . 1985;30:843-844. 11. Berger LA. Chronic afferent loop obstruction diagnosed by ultrasound . Br J Radiol . 1980;53:810-812.Crossref 12. Morse JMD, Lakshman S, Thomas E. Pseudogallbladder appearance in partial afferent loop obstruction in a patient with cholecystectomy . South Med J. 1986; 79:1030-1033.Crossref 13. Burhenne HJ. The iatrogenic afferent loop syndrome . Radiology . 1968;91:942-947.Crossref 14. Rosenthall L, Fonseca C, Arzoumanian A, Hernandez M, Greenberg D. 99mTc hepatobiliary imaging following upper abdominal surgery . Radiology . 1979; 130:735-739.Crossref 15. Gale ME, Gerzof SG, Kiser LC, et al. CT appearance of afferent loop obstruction . AJR Am J Roentgenol . 1982;138:1085-1088.Crossref 16. Kuwabara Y, Nishitani H, Numaguchi Y, Kamoi I, Matsuura K, Saito S. Case report: afferent loop syndrome . J Comput Assist Tomogr . 1980;4:687-689.Crossref 17. Osnes M, Myren J. Endoscopic retrograde cholangio-pancreatography (ERCP) in patients with Billroth II partial gastrectomies . Endoscopy . 1975;7:227-232.Crossref 18. Safrany L. Endoscopy and retrograde cholangio-pancreatography after Billroth II operation . Endoscopy . 1972;4:198-202.Crossref 19. Mitty WF, Grossi C, Nealon TF. Chronic afferent loop syndrome . Ann Surg . 1970;172:996-1001.Crossref 20. Thaker P, Weingarten L, Friedman IH. Stenosis of the small intestine due to nonocclusive ischemic disease . Arch Surg . 1977;112:1216-1217.Crossref 21. Kradjian RM. ischemic stenosis of small intestine . Arch Surg . 1965:91:829-834.Crossref 22. Braun H. Uber Gastroenterostomie und gleichzeitig ausgeführte Enteroanastomose . Arch Clin Chir . 1893;45:361-374. 23. Braasch JW, Brooke-Cowden GL. Disability after gastric surgery . Surg Clin North Am . 1976; 56:607-622. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Recurrent Acute Pancreatitis Caused by Afferent Loop Stricture After Gastrectomy

Mithöfer, Kai; Warshaw, Andrew L.
Archives of Surgery , Volume 131 (5) – May 1, 1996
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References (23)

Publisher
American Medical Association
Copyright
Copyright © 1996 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.1996.01430170107021
Publisher site
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Abstract

Abstract Afferent loop obstruction after gastrectomy and Billroth II gastrojejunostomy is only rarely diagnosed as the cause of recurrent acute pancreatitis. Three patients are described in whom afferent loop stricture after gastrectomy and Billroth II reconstruction manifested as recurrent pancreatitis 13 to 24 years after the initial procedure. Late onset, nonspecific symptoms, and other simultaneous gastrointestinal pathologic features promoted a chronic clinical course in all patients. Symptoms included acute abdominal pain, vomiting, jaundice, hyperamylasemia, weight loss, and anemia. A thorough history, barium examination, cholescintigraphy, and endoscopy were central in establishing the diagnosis. The pathogenesis of stricture formation is thought to be ischemic mucosal damage from intestinal crossclamping. Surgical decompression provided lasting relief of the symptoms. Afferent loop stricture should be considered in the differential diagnosis in patients with recurrent acute pancreatitis and previous gastrectomy with Billroth II reconstruction. (Arch Surg. 1995;131:561-565) References 1. Hinshaw DB, Carter R, Baker HW, Wise RA. Postgastrectomy afferent loop obstruction simulating acute pancreatitis . Ann Surg . 1960;151:600-604.Crossref 2. McMaster P, Wjietjunge DB. Postgastrectomy afferent loop obstruction due to efferent loop herniation simulating acute pancreatitis . Br J Surg . 1976;63:526-527.Crossref 3. Everett WG, Sampson D. Afferent loop obstruction mimicking acute pancreatitis . Br J Surg . 1969;56:843-844.Crossref 4. Conter RL, Converse JO, McGarrity TJ, Koch KL. Afferent loop obstruction presenting as acute pancreatitis and pseudocyst: case reports and review of the literature . Surgery . 1990;108:22-27. 5. Dahlgren S. The afferent loop syndrome . Acta Chir Scand . 1964;327:1-149. 6. Bushkin FL, Woodward ER. The afferent loop syndrome . Maj Probl Clin Surg . 1976;20:34-48. 7. Woodward ER. The pathophysiology of afferent loop syndrome . Surg Clin North Am . 1966;46:411-423. 8. Eagon JC, Miedema BW, Kelly KA. Postgastrectomy syndromes . Surg Clin North Am . 1992;72:445-462. 9. Hoffman WA, Spiro HM. Afferent loop problems . Gastroenterology . 1961;40: 201-209. 10. King PM, Bird DR, Eremin O. Enterolith obstruction of the small bowel . J R Coll Surg Edinb . 1985;30:843-844. 11. Berger LA. Chronic afferent loop obstruction diagnosed by ultrasound . Br J Radiol . 1980;53:810-812.Crossref 12. Morse JMD, Lakshman S, Thomas E. Pseudogallbladder appearance in partial afferent loop obstruction in a patient with cholecystectomy . South Med J. 1986; 79:1030-1033.Crossref 13. Burhenne HJ. The iatrogenic afferent loop syndrome . Radiology . 1968;91:942-947.Crossref 14. Rosenthall L, Fonseca C, Arzoumanian A, Hernandez M, Greenberg D. 99mTc hepatobiliary imaging following upper abdominal surgery . Radiology . 1979; 130:735-739.Crossref 15. Gale ME, Gerzof SG, Kiser LC, et al. CT appearance of afferent loop obstruction . AJR Am J Roentgenol . 1982;138:1085-1088.Crossref 16. Kuwabara Y, Nishitani H, Numaguchi Y, Kamoi I, Matsuura K, Saito S. Case report: afferent loop syndrome . J Comput Assist Tomogr . 1980;4:687-689.Crossref 17. Osnes M, Myren J. Endoscopic retrograde cholangio-pancreatography (ERCP) in patients with Billroth II partial gastrectomies . Endoscopy . 1975;7:227-232.Crossref 18. Safrany L. Endoscopy and retrograde cholangio-pancreatography after Billroth II operation . Endoscopy . 1972;4:198-202.Crossref 19. Mitty WF, Grossi C, Nealon TF. Chronic afferent loop syndrome . Ann Surg . 1970;172:996-1001.Crossref 20. Thaker P, Weingarten L, Friedman IH. Stenosis of the small intestine due to nonocclusive ischemic disease . Arch Surg . 1977;112:1216-1217.Crossref 21. Kradjian RM. ischemic stenosis of small intestine . Arch Surg . 1965:91:829-834.Crossref 22. Braun H. Uber Gastroenterostomie und gleichzeitig ausgeführte Enteroanastomose . Arch Clin Chir . 1893;45:361-374. 23. Braasch JW, Brooke-Cowden GL. Disability after gastric surgery . Surg Clin North Am . 1976; 56:607-622.

Journal

Archives of Surgery – American Medical Association

Published: May 1, 1996

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