S1531 Therapeutic Challenges in Afferent Loop Syndrome Presenting as Recurrent Pancreatitis With Ascending Cholangitis

Abstract

Introduction: Afferent Loop Syndrome (ALS) is a post-surgical complication associated with multiple gastrointestinal surgeries such as partial gastric resections with Billroth II, Roux-en-Y reconstructions, and pancreaticoduodenectomies. ALS occurs from a distal obstruction of the afferent limb resulting in accumulation of bile, pancreatic fluid, or small bowel secretions. Case Description/Methods: A 59-year-old male with a history of peptic ulcer disease status post gastric antrectomy and Billroth II presented to the hospital with one day of abdominal pain. He admitted to nausea and vomiting without fevers or chills. Admission vitals were noncontributory. Physical exam demonstrated tenderness to light palpation in the epigastric region. Initial laboratory results were significant for a leukocytosis of 24.3 K/mm3, lipase of 382 IU/ml, AST of 1,285 IU/ml, ALT of 560 IU/ml, and ALP of 289 IU/ml. Blood cultures grew E. coli. Abdominal CT scan demonstrated a duodenal blind limb dilation with stones present, and MRI-MRCP demonstrated a distended duodenal stump with intraluminal stones. EGD was performed showing evidence of previous Billroth II gastroenterostomy and a stricture in the blind limb of the duodenum. Ceftriaxone was started for cholangitis with ensuing clinical improvement. Endoscopic intervention was deferred due to clinical improvement with medical management with plan for follow up with surgery for definitive management upon discharge. Discussion: The underlying mechanism for obstruction in ALS can be due to adhesions, herniations, scarring from prior ulceration, or malignancies. Abdominal CT is the gold standard for diagnosis, but treatment of ALS can be difficult. Surgery has been the therapeutic mainstay, but endoscopic intervention with lumen-apposing metal stents (LAMS) shows promising results in biliary and duodenal obstructions. LAMS are placed during endoscopic ultrasonography-biliary drainage procedures, and multiple successful approaches have been described in the literature. One technique used is the deployment of LAMS across a gastroenterostomy, bypassing the stricture. Another method is the intraluminal placement of a LAMS directly across an area of stenosis, placing a transmural stent. As our patient showed, treatment of ALS is challenging. Data describing the outcomes and adverse events of endoscopic intervention is limited. Although current evidence of LAMS use is promising, longitudinal studies are needed to better understand the risks and benefits of this procedure.