eMedicine Specialties > Gastroenterology > Intestine

Afferent Loop Syndrome

Author: 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
Coauthor(s): 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; Robert A Decker, MD, Clinical Assistant Professor, Department of Medicine, University of Hawaii at Manoa: Chief, Gastroenterology Service, Kaiser Permanente Medical Center of Honolulu
Contributor Information and Disclosures

Updated: Nov 16, 2009

Introduction

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 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.

Afferent limb syndrome. Kinking of the afferent l...

Afferent limb syndrome. Kinking of the afferent limb at the gastrojejunostomy.

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Afferent limb syndrome. Kinking of the afferent l...

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.

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Afferent limb syndrome. Tracing of kinking of the...

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


For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Peptic Ulcers and Anatomy of the Digestive System.

History of the Procedure

The operations 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 syndrome1
  • Late dumping syndrome2
  • Postvagotomy diarrhea3
  • Chronic gastric atony4
  • Roux stasis syndrome5
  • Small gastric remnant syndrome6
  • Alkaline reflux gastritis7
  • Afferent loop syndrome8
  • Efferent loop syndrome8

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 1950.9 The first detailed exegesis in the English literature on the etiology, clinical presentation, and treatment of ALS was contributed by Wells and Welbourn in 1951.10

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.

Frequency

In the United States, ALS affects approximately 1% of patients undergoing gastric resection and Billroth II gastrojejunostomies. 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.11,12

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

Mortality/Morbidity: Mortality rates of up to 57% have been reported for acute ALS. Mortality is most frequently associated with a delay in 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.

Sex: According to Tovey et al, one or more of the postgastrectomy syndromes is more likely to occur in female patients.13

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

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)14
  • Volvulus of the intestinal segment
  • Enteroenteral or enterogastric intussusception
  • Kinking of the afferent limb at the gastrojejunostomy (see Media files 1-2)
  • Scarring due to marginal (stomal) ulceration15
  • Recurrence of cancer at or near the anastomotic site
  • Enteroliths in the afferent limb16
  • Bezoars in the afferent limb or at the anastomosis17
  • 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.8

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 release of secretin and cholecystokinin. These enteric hormones stimulate 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.19 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.20 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 a 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.

Presentation

History - Acute ALS

Acute ALS is caused by complete obstruction of the afferent loop. However, it is rare and may either occur within a few days postoperatively or present unexpectedly several years after a Billroth II gastrectomy as described by Ballas et al.21 In both circumstances, this condition is caused by acute obstruction of the afferent limb due to herniation or volvulus of the afferent loop posterior to the efferent limb. Patients with acute ALS typically present with a sudden onset of epigastric and/or right or left upper quadrant abdominal pain, with associated nausea and vomiting.

With acute ALS, the vomitus is not bilious because the biliary and pancreatic secretions remain trapped in the obstructed bowel loop. If the afferent loop is not decompressed, the patient becomes acutely ill and can subsequently develop peritonitis and shock if intestinal perforation or infarction ensues.

History - Chronic ALS

Chronic ALS is caused by partial obstruction of the afferent loop and may be more difficult to diagnose than acute ALS. Approximately 10-20 minutes to an hour postprandially, the patient experiences abdominal fullness and epigastric pain. These symptoms usually last from several minutes to an hour, although they occasionally last as long as several days.

Projectile bilious vomiting is a classic manifestation of ALS with partial obstruction. The distended afferent loop decompresses forcefully, providing rapid relief of symptoms. Note that the vomitus usually contains no food because it has progressed along the unobstructed efferent limb. Vomiting may occur after each meal or only occasionally.22 Also, symptoms in the immediate postprandial period may be minimized if the patient assumes a recumbent position.

Prolonged chronic ALS with stasis and bacterial overgrowth can be further complicated by steatorrhea, diarrhea, and vitamin B-12 deficiency anemia. These effects are primarily due to bacterial deconjugation of bile salts. The aforementioned factors, in addition to bypassing the duodenum and proximal jejunum, can result in iron deficiency anemia.

Physical findings

Physical examination can reveal one or more of the following findings:

  • An ill-defined mass in the right upper abdominal quadrant may be present in one-third of patients with acute ALS.
  • Localized midepigastric or right upper abdominal quadrant tenderness
  • Peritonitis and/or a rigid abdomen if necrosis or perforation of the bowel wall has occurred
  • Jaundice
  • Signs of pancreatitis (eg, upper abdominal pain radiating to the flank or back
Differential diagnoses
  • Abdominal abscess
  • Abdominal hernias
  • Acute mesenteric ischemia
  • Anemia
  • Bacterial overgrowth syndrome
  • Benign gastric tumors
  • Benign neoplasm of the small intestine
  • Bile duct strictures
  • Bile duct tumors
  • Biliary colic
  • Biliary obstruction
  • Carcinoma of the ampulla of Vater
  • Choledochal cysts
  • Choledocholithiasis
  • Esophagogastroduodenoscopy
  • Gastric outlet obstruction
  • Gastric sarcoma
  • Gastric ulcers
  • Gastric volvulus
  • Gastritis (acute, atrophic, or chronic)
  • Intestinal perforation
  • Mesenteric artery ischemia
  • Mesenteric artery thrombosis
  • Mesenteric tumors
  • Omental torsion

Other problems to be considered

  • Bile reflux gastritis
  • Pancreatic pseudocyst or cystic tumor
  • Mesenteric cyst
  • Mesenteric lymphoid hamartoma
  • Intra-abdominal abscess
  • Cystic metastases

Indications

Surgery is indicated in most cases of ALS. Recently, successful management of ALS in cases of advanced or recurrent malignancy using image-directed percutaneous drainage techniques has been reported. The fact remains that ALS is a purely mechanical complication consisting of varying degrees of obstruction of the afferent loop and will not resolve without surgery or other interventional techniques.

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.

Contraindications

Surgical correction of ALS has no absolute contraindications. Relative contraindications include severe debilitation or extensive intra-abdominal malignancies. Patients with these conditions can be effectively treated with nonsurgical drainage procedures as described in Treatment.

More on Afferent Loop Syndrome

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Workup: Afferent Loop Syndrome
Treatment: Afferent Loop Syndrome
Follow-up: Afferent Loop Syndrome
Multimedia: Afferent Loop Syndrome
References
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References

  1. Roberts KE, Randall HT, Farr HW, Kidwell AP, Mcneer GP, Pack GT. Cardiovascular and blood volume alterations resulting from intrajeunal administration of hypertonic solutions to gastrectomized patients: the relationship of these changes to the dumping syndrome. Ann Surg. Nov 1954;140(5):631-40. [Medline].

  2. Shultz KT, Neelon FA, Nilsen LB, Lebovitz HE. Mechanism of postgastrectomy hypoglycemia. Arch Intern Med. Aug 1971;128(2):240-6. [Medline].

  3. Emas S, Fernstrom M. Prospective, randomized trial of selective vagotomy with pyloroplasty and selective proximal vagotomy with and without pyloroplasty in the treatment of duodenal, pyloric, and prepyloric ulcers. Am J Surg. Feb 1985;149(2):236-43. [Medline].

  4. Hom S, Sarr MG, Kelly KA, Hench V. Postoperative gastric atony after vagotomy for obstructing peptic ulcer. Am J Surg. Mar 1989;157(3):282-6. [Medline].

  5. Gustavsson S, Ilstrup DM, Morrison P, Kelly KA. Roux-Y stasis syndrome after gastrectomy. Am J Surg. Mar 1988;155(3):490-4. [Medline].

  6. Delcore R, Cheung LY. Surgical options in postgastrectomy syndromes. Surg Clin North Am. Feb 1991;71(1):57-75. [Medline].

  7. Ritchie WP Jr. Alkaline reflux gastritis. An objective assessment of its diagnosis and treatment. Ann Surg. Sep 1980;192(3):288-98. [Medline].

  8. Eagon JC, Miedema BW, Kelly KA. Postgastrectomy syndromes. Surg Clin North Am. Apr 1992;72(2):445-65. [Medline].

  9. Roux G, Pedoussaut R, Marchal G. [Afferent loop syndrome of gastrectomized subjects.]. Lyon Chir. Oct 1950;45(7):773-80. [Medline].

  10. Wells C, Welbourn R. Post-gastrectomy syndromes; a study in applied physiology. Br Med J. Mar 17 1951;1(4706):546-54. [Medline].

  11. Burkhalter E. Incidence of gastrectomy in United States army hospitals worldwide from 1975 to 1985. Am J Gastroenterol. Nov 1988;83(11):1231-4. [Medline].

  12. Paimela H, Tuompo PK, Perakyl T, Saario I, Hockerstedt K, Kivilaakso E. Peptic ulcer surgery during the H2-receptor antagonist era: a population-based epidemiological study of ulcer surgery in Helsinki from 1972 to 1987. Br J Surg. Jan 1991;78(1):28-31. [Medline].

  13. Tovey FI, Godfrey JE, Lewin MR. A gastrectomy population: 25-30 years on. Postgrad Med J. Jun 1990;66(776):450-6. [Medline].

  14. Ogata M, Ishikawa T. Acute afferent loop obstruction caused by retroanastomotic hernia. J Ultrasound Med. Nov 1993;12(11):697-9. [Medline].

  15. Tsutsui S, Kitamura M, Shirabe K, Baba H, Sugimachi K. Afferent loop syndrome due to scarring of a stomal ulcer following a Billroth II gastrectomy. Endoscopy. Jun 1995;27(5):410. [Medline].

  16. Carbognin G, Biasiutti C, El-Khaldi M, Ceratti S, Procacci C. Afferent loop syndrome presenting as enterolith after Billroth II subtotal gastrectomy: a case report. Abdom Imaging. Mar-Apr 2000;25(2):129-31. [Medline].

  17. Hui MS, Perng HL, Choi WM, Chem LK, Yang KC, Chen TJ. Afferent loop syndrome complicated by a duodenal phytobezoar after Billroth-II subtotal gastrectomy. Am J Gastroenterol. Sep 1997;92(9):1550-2. [Medline].

  18. Bushkin FL, Woodward ER. The afferent loop syndrome. Major Probl Clin Surg. 1976;20:34-48. [Medline].

  19. Locke GR, Alexander GL, Sarr MG. Obstructive jaundice: an unusual presentation of afferent loop obstruction. Am J Gastroenterol. Jun 1994;89(6):942-4. [Medline].

  20. Rana SV, Bhardwaj SB. Small intestinal bacterial overgrowth. Scand J Gastroenterol. 2008;43(9):1030-7. [Medline].

  21. Ballas KD, Rafailidis SE, Konstantinidis HD, et al. Acute afferent loop syndrome: a true emergency. A case report. Acta Chir Belg. Jan-Feb 2009;109(1):101-3. [Medline].

  22. Golioto M. A woman with abdominal pain and bilious vomiting. A very late aftermath of Billroth II gastrectomy. N C Med J. Nov-Dec 2000;61(6):338-40. [Medline].

  23. Kitamura H, Miwa S, Nakata T, Nomura K, Tanaka T, Ikegami T, et al. Sonographic detection of visceral adhesion in percutaneous drainage of afferent-loop small-intestine obstruction. J Clin Ultrasound. Mar 2000;28(3):133-6. [Medline].

  24. Derchi LE, Bazzocchi M, Brovero PL. Sonographic diagnosis of obstructed afferent loop. Gastrointest Radiol. 1992;17(2):105-7. [Medline].

  25. Lee DH, Lim JH, Ko YT. Afferent loop syndrome: sonographic findings in seven cases. AJR Am J Roentgenol. Jul 1991;157(1):41-3. [Medline].

  26. Matsusue S, Kashihara S, Takeda H, Koizumi S. Three cases of afferent loop obstruction--the role of ultrasonography in the diagnosis. Jpn J Surg. Nov 1988;18(6):709-13. [Medline].

  27. Lai FM, Paramsothy M, George J, Yip CH. The role of 99mtechnetium (Tc) diethyl-iminodiacetic acid (EHIDA) hepatobiliary scintigraphy in the diagnosis of a rare cause of obstructive jaundice. Singapore Med J. Jun 1996;37(3):261-3. [Medline].

  28. Sivelli R, Farinon AM, Sianesi M, Percudani M, Ugolotti G, Calbiani B. Technetium-99m HIDA hepatobiliary scanning in evaluation of afferent loop syndrome. Am J Surg. Aug 1984;148(2):262-5. [Medline].

  29. Yilmaz S, Yekeler E, Dural C, et al. Afferent loop syndrome secondary to Billroth II gastrojejunostomy obstruction: Multidetector computed tomography findings. Surgery. Apr 2007;141(4):538-9. [Medline].

  30. Zissin R, Hertz M, Paran H, Osadchy A, Gayer G. Computed tomographic features of afferent loop syndrome: pictorial essay. Can Assoc Radiol J. Apr 2005;56(2):72-8. [Medline].

  31. Kim HC, Han JK, Kim KW, Kim YH, Yang HK, Kim SH, et al. Afferent loop obstruction after gastric cancer surgery: helical CT findings. Abdom Imaging. Sep-Oct 2003;28(5):624-30. [Medline].

  32. Gayer G, Barsuk D, Hertz M, Apter S, Zissin R. CT diagnosis of afferent loop syndrome. Clin Radiol. Sep 2002;57(9):835-9. [Medline].

  33. Gale ME, Gerzof SG, Kiser LC, Snider JM, Stavis DM, Larsen CR, et al. CT appearance of afferent loop obstruction. AJR Am J Roentgenol. Jun 1982;138(6):1085-8. [Medline].

  34. Swayne LC, Love MB. Computed tomography of chronic afferent loop obstruction: a case report and review. Gastrointest Radiol. 1985;10(1):39-41. [Medline].

  35. Kuwabara Y, Nishitani H, Numaguchi Y, Kamoi I, Matsuura K, Saito S. Afferent loop syndrome. J Comput Assist Tomogr. Oct 1980;4(5):687-9. [Medline].

  36. Chevallier P, Gueyffier C, Souci J, Oddo F, Diaine B, Padovani B. [MRI of an afferent loop syndrome presenting as obstructive icterus]. J Radiol. Feb 2001;82(2):177-9. [Medline].

  37. McKee JD, Raju GP, Edelman RR, Levine H, Steer M, Chuttani R. MR cholangiopancreatography (MRCP) in diagnosis of afferent loop syndrome presenting as cholangitis. Dig Dis Sci. Oct 1997;42(10):2082-6. [Medline].

  38. Ashida A, Tamura I, Kumagiri Y, et al. Magnetic resonance cholangiopancreatography for afferent loop syndrome. ANZ J Surg. Jan-Feb 2008;78(1-2):91-2. [Medline].

  39. Yavuz N, Erguney S, Ogut G, Alver O. Enteroliths developed in a chronically obstructed afferent loop coexisting with gastric remnant carcinoma: Case report and review of the literature. J Gastroenterol Hepatol. Mar 2006;21(3):495-8. [Medline].

  40. Kim YH, Han JK, Lee KH, Kim TK, Kim KW, Choi BI. Palliative percutaneous tube enterostomy in afferent-loop syndrome presenting as jaundice: clinical effectiveness. J Vasc Interv Radiol. Aug 2002;13(8):845-9. [Medline].

  41. Lee KD, Liu TW, Wu CW, Tiu CM, Liu JM, Chung TR, et al. Non-surgical treatment for afferent loop syndrome in recurrent gastric cancer complicated by peritoneal carcinomatosis: percutaneous transhepatic duodenal drainage followed by 24-hour infusion of high-dose fluorouracil and leucovorin. Ann Oncol. Jul 2002;13(7):1151-5. [Medline].

  42. Caldicott DG, Ziprin P, Morgan R. Transhepatic insertion of a metallic stent for the relief of malignant afferent loop obstruction. Cardiovasc Intervent Radiol. Mar-Apr 2000;23(2):138-40. [Medline].

  43. Yoshida H, Mamada Y, Taniai N, Kawano Y, Mizuguchi Y, Shimizu T, et al. Percutaneous transhepatic insertion of metal stents with a double-pigtail catheter in afferent loop obstruction following distal gastrectomy. Hepatogastroenterology. May-Jun 2005;52(63):680-2. [Medline].

  44. Yoshida H, Mamada Y, Taniai N, et al. Afferent loop obstruction treated by percutaneous transhepatic insertion of an expandable metallic stent. Hepatogastroenterology. Sep-Oct 2008;55(86-87):1767-9. [Medline].

  45. Chevallier P, Novellas S, Motamedi JP, et al. Percutaneous jejunostomy and stent placement for treatment of malignant Roux-en-Y obstruction: a case report. Clin Imaging. Jul-Aug 2006;30(4):283-6.

  46. Song HY, Kim TH, Choi EK, et al. Metallic stent placement in patients with recurrent cancer after gastrojejunostomy. J Vasc Interv Radiol. Dec 2007;18(12):1538-46. [Medline].

  47. Kim HJ, Kim JW, Kim KH, et al. [A case of afferent loop syndrome treated by endoscopic drainage procedure using nasogastric tube] [Korean]. Korean J Gastroenterol. Mar 2007;49(3):173-6. [Medline].

  48. Borrelli D, Borrelli A, Presenti L, Bergamini C, Basili G. [Surgical approach of the functional post-partial gastrectomy syndromes] [Italian]. Ann Ital Chir. Jan-Feb 2007;78(1):3-10. [Medline].

  49. Vettoretto N, Pettinato G, Romessis M, Bravo AF, Barozzi G, Giovanetti M. Laparoscopy in afferent loop obstruction presenting as acute pancreatitis. JSLS. Apr-Jun 2006;10(2):270-4. [Medline].

  50. Aimoto T, Uchida E, Nakamura Y, Katsuno A, Chou K, Tajiri T, et al. Malignant afferent loop obstruction following pancreaticoduodenectomy: report of two cases. J Nippon Med Sch. Aug 2006;73(4):226-30. [Medline].

  51. Van Stiegmann G, Goff JS. An alternative to Roux-en-Y for treatment of bile reflux gastritis. Surg Gynecol Obstet. Jan 1988;166(1):69-70. [Medline].

  52. Mulholland MW, Magallanes F, Quigley TM, Delaney JP. In-continuity gastrointestinal stapling. Dis Colon Rectum. Sep 1983;26(9):586-9. [Medline].

  53. Aerts P, Leyman P, Verellen S, Van Steenberge R. Ultrasonography and computed tomography of afferent loop obstruction. J Belge Radiol. Dec 1993;76(6):390-1. [Medline].

  54. Fleser PS, Villalba M. Afferent limb volvulus and perforation of the bypassed stomach as a complication of Roux-en-Y gastric bypass. Obes Surg. Jun 2003;13(3):453-6. [Medline].

  55. Kaya E, Senyürek G, Dervisoglu A, Danaci M, Kesim M. Acute pancreatitis caused by afferent loop herniation after Billroth II gastrectomy: report of a case and review of the literature. Hepatogastroenterology. Mar-Apr 2004;51(56):606-8. [Medline].

  56. Lee LI, Teplick SK, Haskin PH, Sammon JK, Wolferth C, Amron G. Refractory afferent loop problems: percutaneous transhepatic management of two cases. Radiology. Oct 1987;165(1):49-50. [Medline].

  57. Mann NS, Rachut E. Carcinoma of gastric stump causing afferent loop obstruction and acute pancreatitis. Hepatogastroenterology. Jan-Feb 2004;51(55):184-5. [Medline].

  58. Morii Y, Arita T, Shimoda K, Yasuda K, Matsui Y, Inomata M, et al. Jejunal interposition to prevent postgastrectomy syndromes. Br J Surg. Nov 2000;87(11):1576-9. [Medline].

  59. Moriura S, Takayama Y, Nagata J, Akutagawa A, Hirano A, Ishiguro S, et al. Percutaneous bowel drainage for jaundice due to afferent loop obstruction following pancreatoduodenectomy: report of a case. Surg Today. 1999;29(10):1098-101. [Medline].

  60. Morse JM, Lakshman S, Thomas E. "Pseudogallbladder" appearance in partial afferent loop obstruction in a patient with cholecystectomy. South Med J. Aug 1986;79(8):1030-3. [Medline].

  61. Muthukrishnan A, Shanthly N, Kumar S. Afferent loop syndrome: the role of Tc-99m mebrofenin hepatobiliary scintigraphy. Clin Nucl Med. Jun 2000;25(6):492-4. [Medline].

  62. Taylor AR, Russ PD, Lee RE, Weingardt JP. Acute afferent loop obstruction diagnosed with computed tomography: case report. Can Assoc Radiol J. Aug 1999;50(4):251-4. [Medline].

  63. Tien YW, Lee PH, Chang KJ. Enterolith: an unusual cause of afferent loop obstruction. Am J Gastroenterol. May 1999;94(5):1391-2. [Medline].

  64. Woodfield CA, Levine MS. The postoperative stomach. Eur J Radiol. Mar 2005;53(3):341-52. [Medline].

  65. Yao NS, Wu CW, Tiu CM, Liu JM, Whang-Peng J, Chen LT. Percutaneous transhepatic duodenal drainage as an alternative approach in afferent loop obstruction with secondary obstructive jaundice in recurrent gastric cancer. Cardiovasc Intervent Radiol. Jul-Aug 1998;21(4):350-3. [Medline].

  66. Zissin R. CT findings of afferent loop syndrome after a subtotal gastrectomy with Roux-en-Y reconstruction. Emerg Radiol. Feb 2004;10(4):201-3. [Medline].

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Further Reading

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Keywords

afferent loop syndrome, ALS, Billroth II gastrojejunostomy, hernia, volvulus, intussusception, blind loop syndrome, proximal loop syndrome, postgastrectomy syndromes, late dumping syndrome, intestinal obstruction,

postvagotomy diarrhea, chronic gastric atony, Roux stasis syndrome, small gastric remnant syndrome, alkaline reflux gastritis, efferent loop syndrome, peptic ulcer disease, PUD, gastrojejunal loop obstruction, gastrojejunostomy, Billroth II-type gastrectomy, pancreaticoduodenectomy, esophagogastroduodenoscopy, EGD, Billroth I gastroduodenostomy, Roux-en-Y gastrojejunostomy

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Contributor Information and Disclosures

Author

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
Sandeep Mukherjee, MB, BCh, MPH, FRCPC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Coauthor(s)

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.

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.

Medical Editor

Rajeev Vasudeva, MD, FACG, Clinical Professor of Medicine, Consultants in Gastroenterology, University of South Carolina School of Medicine
Rajeev Vasudeva, MD, FACG is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Columbia Medical Society, South Carolina Gastroenterology Association, and South Carolina Medical Association
Disclosure: Pricara Honoraria Speaking and teaching; UCB Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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, and American Gastroenterological Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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