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Afferent Loop Syndrome

  • Author: Suresh Kumar Nayudu, MD; Chief Editor: BS Anand, MD  more...
 
Updated: Jul 19, 2016
 

Background

Afferent loop syndrome (ALS) is a purely mechanical complication that infrequently occurs following construction of a gastrojejunostomy. Creation of an anastomosis between the stomach and jejunum leaves a segment of the small bowel, most commonly consisting of duodenum and proximal jejunum, lying upstream from the gastrojejunostomy. This limb of intestine conducts bile, pancreatic juices, and other proximal intestinal secretions toward the gastrojejunostomy and is thus termed the afferent loop. See the images below.

Afferent limb syndrome. Kinking of the afferent li Afferent limb syndrome. Kinking of the afferent limb at the gastrojejunostomy.
Afferent limb syndrome. Tracing of kinking of the Afferent limb syndrome. Tracing of kinking of the afferent limb at the gastrojejunostomy.

For patient education resources, see Digestive Disorders Center, as well as Peptic Ulcers and Anatomy of the Digestive System.

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Relevant Anatomy

The afferent loop consists of the duodenal stump, the remainder of the duodenum, and the segment of jejunum proximal to the gastrojejunostomy. The clinically relevant portion of the loop pertaining to ALS is the jejunal portion of the afferent limb. The jejunal limb is subject to adhesion formation, internal herniation, volvulus, anastomotic obstruction, and other etiologies of ALS, as previously described.

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Pathophysiology

Problem

ALS manifests in acute and chronic forms. Acute ALS represents complete obstruction of the afferent loop and is a true surgical emergency. It must be diagnosed and corrected expeditiously. Chronic ALS is associated with partial obstruction. It is not a surgical emergency but does require corrective surgery.

Pathophysiology

An afferent loop is composed of the duodenal stump, the remainder of the duodenum, and the segment of jejunum located proximal to a Billroth II–type gastrojejunostomy. ALS is caused by complete or partial mechanical obstruction at the gastrojejunostomy or at a point along the jejunal portion of the afferent loop.

Passage of food and gastric secretions through the gastrojejunostomy and into the efferent loop triggers the release of secretin and cholecystokinin. These enteric hormones stimulate the secretion of bile, pancreatic enzymes, and pancreatic bicarbonate and water into the afferent loop. Under gastrointestinal hormonal influence, up to 1-2 L of pancreatic and biliary secretions can enter the afferent loop each day.

Symptoms associated with ALS are caused by increased intraluminal pressure and distention due to accumulation of enteric secretions in a partially or completely obstructed afferent limb. ALS is one of the main causes of duodenal stump blowout in the early postoperative period and is also an etiology for postoperative obstructive jaundice, ascending cholangitis, and pancreatitis due to transmission of high pressures back to the biliopancreatic ductal system.[1] High luminal pressures and distention increase bowel wall tension in the afferent loop (in accord with the Laplace law) and can lead to ischemia and gangrene with subsequent perforation and peritonitis.

Secondarily, prolonged stasis and pooling of secretions with partial obstruction facilitate bacterial overgrowth in the afferent loop.[2] Bacteria deconjugate bile acids, which can lead to steatorrhea, malnutrition, and vitamin B-12 deficiency leading to megaloblastic anemia.

A variety of investigations have been performed to confirm the diagnosis of bacterial overgrowth and include jejunal aspiration, 14 carbon D-xylose breath testing, hydrogen breath testing using glucose or galactose, and 14 carbon-glycocholic breath testing. However, as none of these investigations have been standardized, treatment is often initiated clinically when there is a high index of suspicion. Although the mechanism behind iron deficiency is complex, iron deficiency can also develop due to bypassing of the proximal small bowel and achlorhydria which impairs iron solubility.

The severity at presentation mainly depends on the degree and duration of obstruction.

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History of the Procedure

The surgical procedures most commonly associated with this complication include distal or subtotal gastrectomies for peptic ulcer disease or gastric malignancies with Billroth II reconstructions, pancreaticoduodenectomies, and gastrojejunostomies performed to bypass other foregut pathology. The pathophysiology and signs and symptoms associated with ALS result from partial or complete obstruction of the afferent loop.

ALS is included in the constellation of resectional gastric surgical complications known as the postgastrectomy syndromes. The following syndromes are included:

  • Early dumping syndrome [3]
  • Late dumping syndrome [4]
  • Postvagotomy diarrhea [5]
  • Chronic gastric atony [6]
  • Roux stasis syndrome [7]
  • Small gastric remnant syndrome [8]
  • Alkaline reflux gastritis [9]
  • Afferent loop syndrome [10]
  • Efferent loop syndrome [10]

Patients with ALS may present with an acute, completely obstructed form or with a chronic, partially obstructed form. The syndrome can manifest at any time from the first postoperative day to many years after surgery. The acute form usually occurs in the early postoperative period (1-2 wk), but it has been described to occur 30-40 years after surgery.

In 1942, McNealy first described acute ALS as a cause of early postoperative duodenal stump leakage. Lake is credited with recognizing the chronic form in 1948. Roux and coworkers coined the term afferent loop syndrome in 1950.[11] The first detailed description in the English literature of the etiology, clinical presentation, and treatment of ALS was contributed by Wells and Welbourn in 1951.[12]

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Etiology

Postoperative conditions

Each of the following postoperative conditions can cause ALS in a patient with a gastrojejunostomy:

  • Entrapment or compression of the afferent loop by postoperative adhesions
  • Internal hernia (eg, through a mesocolic defect) [13]
  • Volvulus of the intestinal segment
  • Enteroenteral or enterogastric intussusception
  • Kinking of the afferent limb at the gastrojejunostomy (see the following images)
    Afferent limb syndrome. Kinking of the afferent li Afferent limb syndrome. Kinking of the afferent limb at the gastrojejunostomy.
    Afferent limb syndrome. Tracing of kinking of the Afferent limb syndrome. Tracing of kinking of the afferent limb at the gastrojejunostomy.
  • Scarring due to marginal (stomal) ulceration [14]
  • Recurrence of cancer at or near the anastomotic site
  • Enteroliths in the afferent limb [15, 16]
  • Bezoars in the afferent limb or at the anastomosis [17]
  • Foreign bodies in the afferent limb or at the anastomosis

Surgical technique

Patients have an increased chance of developing ALS if one or more of the following conditions is met:

  • The jejunal portion of the afferent limb is longer than 30-40cm in length.
  • The gastrojejunostomy is placed in an antecolic position instead of a retrocolic position.
  • Mesocolic defects are not properly closed after construction of a retrocolic gastrojejunostomy.

Bushkin and Woodward reported an equal incidence of ALS in patients with short, retrocolic afferent limbs.[18] However, according to Eagon and coworkers, most authors opine that longer, redundant, and antecolic afferent limbs are more prone to kinking, volvulus, and entrapment by adhesions.[10]

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Epidemiology

United States and international data

In the United States, ALS affects approximately 1% of patients undergoing gastric resection and Billroth II gastrojejunostomy. This figure may be an underestimation because this complication is probably underdiagnosed. Overall, the incidence of this complication decreased dramatically during the final quarter of the 20th century as elective gastric surgery for complications of peptic ulcer disease underwent a logarithmic decline.[19, 20]

Internationally, rates for the development of this complication appear to be similar in other nations.

Sex- and age-related demographics

According to Tovey et al, one or more of the postgastrectomy syndromes is more likely to occur in female patients.[21]

ALS favors no particular age group on a per capita basis.

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Prognosis

After a proper corrective procedure, the prognosis is usually very good, except in cases of advanced or recurrent malignancy.

Mortality/morbidity

Mortality rates of up to 57% have been reported for acute ALS. Mortality is most frequently associated with a delay in the diagnosis that leads to bowel infarction or rupture and peritonitis. Patients in whom a timely diagnosis is made or who present with chronic manifestations of the disease can undergo corrective surgery with acceptably low morbidity and mortality rates. 

Complications

Patients undergoing surgery for ALS are at risk of developing any of the following complications:

  • Wound infection
  • Wound dehiscence with or without evisceration
  • Urinary tract infection
  • Atelectasis
  • Pneumonia
  • Anastomotic disruption
  • Anastomotic stricture
  • Marginal ulceration
  • Intra-abdominal abscess formation
  • Cholangitis
  • Delayed gastric emptying/gastroparesis
  • Internal or enterocutaneous fistulae
  • Small bowel obstruction
  • Dumping syndrome
  • Alkaline reflux gastritis
  • Roux stasis syndrome
  • Cardiac arrhythmias
  • Deep venous thrombosis
  • Pulmonary embolism
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Contributor Information and Disclosures
Author

Suresh Kumar Nayudu, MD Fellow in Gastroenterology, Bronx-Lebanon Hospital Center, Albert Einstein College of Medicine of Yeshiva University

Suresh Kumar Nayudu, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Medical Society of the State of New York, American Association of Physicians of Indian Origin, Americas Hepato-Pancreato-Biliary Association

Disclosure: Nothing to disclose.

Coauthor(s)

Prospere Remy, MD Assistant Professor of Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Internal Medicine, Bronx-Lebanon Hospital Center

Prospere Remy, MD is a member of the following medical societies: American College of Physicians, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Haritha Reddy Chelimilla, MD Fellow, Department of Gastroenterology, Bronx-Lebanon Hospital Center

Haritha Reddy Chelimilla, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Medical Association, Medical Society of the State of New York, Indian Medical Association, New York Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Hassan Tariq, MD Chief Resident, Department of Medicine, Bronx Lebanon Hospital Center

Hassan Tariq, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Douglas M Heuman, MD, FACP, FACG, AGAF Chief of Hepatology, Hunter Holmes McGuire Department of Veterans Affairs Medical Center; Professor, Department of Internal Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine

Douglas M Heuman, MD, FACP, FACG, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Physicians, American Gastroenterological Association

Disclosure: Received grant/research funds from Novartis for other; Received grant/research funds from Bayer for other; Received grant/research funds from Otsuka for none; Received grant/research funds from Bristol Myers Squibb for other; Received none from Scynexis for none; Received grant/research funds from Salix for other; Received grant/research funds from MannKind for other.

Chief Editor

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Additional Contributors

Rajeev Vasudeva, MD Clinical Professor of Medicine, Consultants in Gastroenterology, University of South Carolina School of Medicine

Rajeev Vasudeva, MD is a member of the following medical societies: American College of Gastroenterology, Columbia Medical Society, South Carolina Gastroenterology Association, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, South Carolina Medical Association

Disclosure: Received honoraria from Pricara for speaking and teaching; Received consulting fee from UCB for consulting.

Acknowledgements

Robert A Decker, MD Clinical Assistant Professor, Department of Medicine, University of Hawaii at Manoa: Chief, Gastroenterology Service, Kaiser Permanente Medical Center of Honolulu

Disclosure: Nothing to disclose.

Sandeep Mukherjee, MB, BCh, MPH, FRCPC Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center

Disclosure: Merck Honoraria Speaking and teaching; Ikaria Pharmaceuticals Honoraria Board membership Michael AJ Sawyer, MD Consulting Staff, Department of Surgery, Southwestern Medical Center; Consulting Staff, Department of Surgery, Comanche County Memorial Hospital; Consulting Staff, Great Plains Surgical Clinic, Inc

Michael AJ Sawyer, MD is a member of the following medical societies: American College of Surgeons, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, and Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

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Afferent limb syndrome. Kinking of the afferent limb at the gastrojejunostomy.
Afferent limb syndrome. Tracing of kinking of the afferent limb at the gastrojejunostomy.
Afferent limb syndrome. Normal anatomy and Billroth II gastrojejunostomy.
Afferent limb syndrome. Roux-en-Y gastrojejunostomy.
 
 
 
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