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^[24] and Valdivielso Cortázar et al.^[25]In both circumstances, this condition is caused by an 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.

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 may 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 which passes through the unobstructed efferent limb. Vomiting may occur after each meal or only occasionally.^[26]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 Examination

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

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Media Gallery

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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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)

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.

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.

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, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Columbia Medical Society, South Carolina Gastroenterology Association, 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.