Does She Have a Double Stomach?

Abstract

Introduction: A 33-year-old female with history of GERD, Nissen fundoplication with truncal bilateral vagotomy, pyloroplasty, and gastrojejunostomy presented to our clinic with a history of gastroparesis, constipation, severe post-prandial abdominal pain, bloating, nausea, and vomiting that started after her gastrojejunostomy. Physical examination was significant for an abdominal succussion splash and mild epigastric tenderness. Labs were unremarkable. We recommended an EGD with duodenal aspirates, smart pill study, and antroduodenal manometry. EGD demonstrated severe bile gastritis, a large dilated stomach with absent motility, partially intact Nissen fundoplication, widely patent pyloroplasty, patent gastro-jejunostomy, and a 15-20 cm jejunal loop connecting back to the distal duodenum in a Roux-en-Y anastomosis. The smart pill demonstrated delayed gastric emptying and delayed whole gut/small bowel transit time. An increase in pH was noted upon entry of the smart pill into the small bowel, with a transient decrease in pH to gastric levels approximately 8 hours after entering the small bowel. The patient’s altered anatomy likely accounted for the smart pill entry into the jejunostomy, followed by entry into the duodenum approximately 20 cm distal to the pylorus as seen on EGD. The pill may have encountered an increased acidic environment at this point due to known pyloroplasty or secondary to transient retrograde movement back into the gastric antrum. The smart pill is an orally ingested, non-digestible data recording device that enables measurement of gastric emptying, and small bowel, colonic, and whole gut transit times, as well as pH, pressure, and temperature. The test was selected for this patient to evaluate gastroparesis refractory to medical therapy. The smart pill provided a single transit study to assess transit times and determine the presence of delayed gastric emptying throughout her GI tract. Furthermore, the pill demonstrated tracings consistent with altered anatomy status-post gastrojejunostomy, a possible cause for this patient’s gastroparesis with retrograde movement of food demonstrated by two distinct pH drops. This information was significant as it allowed us to appropriately direct therapy and provided improved causal understanding of her symptoms, as well as preventing the pursuit of therapeutic interventions that might worsen her symptoms, such as repeat surgery.Figure 1