Fluctuating Jaundice: A Rare Presentation of Afferent Loop Syndrome

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Conference Proceeding

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Publication Title

American Journal of Gastroenterology


Introduction: Afferent Loop Syndrome (ALS) is one of the rare complications that can occur post-gastrectomy due to obstruction of the afferent (biliopancreatic) limb. It can present with various symptoms such abdominal pain, nausea, vomiting or jaundice. It can also present as a surgical emergency when complicated by intestinal ischemia and perforation. Here we present a case of fluctuating jaundice due to ALS, which resolved after revision of anastomosis. Case Description/Methods: An 84 year old man presented to office for fluctuating jaundice. He had a history of distal gastrectomy with Billroth II anastomosis at age 27. On month ago, he underwent extension of distal gastrectomy and Roux-en-Y gastrojejunostomy for bleeding gastric ulcer. Post-operatively, his liver enzymes peaked with total bilirubin to 12.6 mg/dl (normal 0.3-1.2 mg/dl), and direct bilirubin to 9.7mg/dl (normal 0.0 -0.4 mg/dl). Computed Tomography (CT) revealed normal bile ducts, but persistent extensive duodenal distension with obstruction just past the ligament of Treitz, likely at the duodenojejunal anastomosis. HIDA scan revealed prompt uptake of the tracer in the liver but no excretion in the biliary tree or small bowel at 1 hour, attributed to increased intraduodenal pressure. On current presentation, he complained of postprandial bloating and discomfort. He was visibly jaundiced with significantly elevated liver enzymes. A week later, he developed acute abdominal pain. Labs were notable for further elevation of liver enzymes. US showed new mild CBD dilation of 8 mm. CT demonstrated 5 cm dilation of the pancreaticobiliary limb with transition point at enteroenteric anastomosis. He underwent exploratory laparotomy which revealed a brisk angulation at the duodenojejunostomy resulting in a functional volvulus. After surgical reduction and revision of duodenojejunostomy, patient had resolution of symptoms with long-term normalization of liver enzymes (Figure 1, Table 1). Discussion: ALS should be considered in the differential diagnosis of obstructive jaundice in post-gastrectomy patients. A clue to diagnosis is presence of a distended biliary limb. HIDA scan can also aid diagnosis by demonstrating a delay in the bilioduodenal transit time. Surgical revision of the anastomosis is the mainstay therapy. Timely diagnosis of ALS is paramount in preventing further morbidity and mortality related to complications.





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American College of Gastroenterology Annual Scientific Meeting, October 20-25, 2023, Vancouver, Canada

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