Stomach 41-50

Q41) Not true about afferent loop syndrome

a) It can  occur after either partial or total gastrectomy with Billroth ii reconstruction or roux en y gastrojejunostomy

b) Acute obstruction is more common than chronic

c)  Weight loss and anemia are common. 

d) Bacterial overgrowth in  afferent limb causes  malabsorption of fat and other nutrients, such as vitamin B12 or iron. 

 

Ans  41 is b

Chronic obstruction is more common. chronic partial obstruction is the more common clinical manifestation.

The classic presentation of chronic afferent loop syndrome is postprandial abdominal pain relieved by bilious vomiting, but the latter may be lacking with Roux-en-Y GJ. 

SKF page 725

Pain builds up for 40-60 mins after meals and then the contents empty in the stomach causing bilious vomiting

Vomiting relieves pain

The etiology  of afferent loop syndrome

(1) entrapment, compression, and kinking of the afferent loop by postoperative adhesions

2. internal hernias

3. volvulus , intussusception of afferent loop

4. marginal ulceration at gj site

5. cancer recurrence (local or lymph node)

Important 

Afferent limb to be kept shorter than 30 cm to prevent it

weight loss, upper abdominal distention, upper abdominal mass, and abdominal tenderness.

Peritoneal findings or pain out of proportion to physical findings are ominous.

Rarely jaundice, cholangitis, or pancreatitis can confuse the clinical picture.

Treatment 

Diagnostic is CT

Primary cause of afferent loop obstruction should be confirmed and treated.

Braun anastomosis in a former Billroth II reconstruction

excision of the redundant loop and conversion of Billroth II to Roux-en-Y GJ or Billroth I

excision of the redundant loop and reconstruction of the former Roux-en-Y jejunojejunostomy

 

Percutaneous and endoscopic relief of the obstruction also have been reported. For patients with malignant recurrences and short survival, surgery may be avoided by endoscopic placement of a self-expanding stent within the obstructed afferent limb.

Alternatively,
for patients with obstructive jaundice and dilated biliary ducts, percutaneous transhepatic self-expanding nitinol stenting has been described