Clin Endosc.  2014 Jul;47(4):367-370. 10.5946/ce.2014.47.4.367.

Electrohydraulic Lithotripsy of an Impacted Enterolith Causing Acute Afferent Loop Syndrome

• Cho YS
• Lee TH
• Hwang SO
• Lee S
• Jung Y
• Chung IK
• Park SH
• Kim SJ

• KMID: 1907941
• DOI: http://doi.org/10.5946/ce.2014.47.4.367

Abstract

Afferent loop syndrome caused by an impacted enterolith is very rare, and endoscopic removal of the enterolith may be difficult if a stricture is present or the normal anatomy has been altered. Electrohydraulic lithotripsy is commonly used for endoscopic fragmentation of biliary and pancreatic duct stones. A 64-year-old man who had undergone subtotal gastrectomy and gastrojejunostomy presented with acute, severe abdominal pain for a duration of 2 hours. Initially, he was diagnosed with acute pancreatitis because of an elevated amylase level and pain, but was finally diagnosed with acute afferent loop syndrome when an impacted enterolith was identified by computed tomography. We successfully removed the enterolith using direct electrohydraulic lithotripsy conducted using a transparent cap-fitted endoscope without complications. We found that this procedure was therapeutically beneficial.

Keyword

Afferent loop syndrome; Enterolith; Electrohydraulic lithotripsy

MeSH Terms

Abdominal Pain
Afferent Loop Syndrome*
Amylases
Constriction, Pathologic
Endoscopes
Gastrectomy
Gastric Bypass
Humans
Lithotripsy*
Middle Aged
Pancreatic Ducts
Pancreatitis
Amylases

Figure

• 

  Fig. 1 (A) An axial abdominal computed tomography (CT) image showing a large impacted enterolith (arrow) in the dilated fluid-filled afferent loop. (B) Coronal CT reconstruction better demonstrating the afferent loop obstruction by the enterolith (arrow).

• 

  Fig. 2 (A) Endoscopically, an impacted yellow enterolith is apparent in the afferent loop. (B) Contrast material could not pass the obstruction due to the completely impacted enterolith on the fluoroscopic image.

• 

  Fig. 3 (A) The enterolith is pulverized via electrohydraulic lithotripsy. (B) The fragmented enterolith after endoscopic removal. (C) A very large ulcerative lesion on a blind pouch of the afferent loop.

Reference

1. Jordan GL Jr. Surgical management of postgastrectomy problems. Arch Surg. 1971; 102:251–259. PMID: 5553296.

2. Wise SW. Case 24: afferent loop syndrome. Radiology. 2000; 216:142–145. PMID: 10887240.

3. Lee MC, Bui JT, Knuttinen MG, Gaba RC, Scott Helton W, Owens CA. Enterolith causing afferent loop obstruction: a case report and literature review. Cardiovasc Intervent Radiol. 2009; 32:1091–1096. PMID: 19365684.

4. Kim HJ, Moon JH, Choi HJ, et al. Endoscopic removal of an enterolith causing afferent loop syndrome using electrohydraulic lithotripsy. Dig Endosc. 2010; 22:220–222. PMID: 20642613.

5. 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. 2000; 25:129–131. PMID: 10675451.

6. Kim JK, Park CH, Huh JH, et al. Endoscopic management of afferent loop syndrome after a pylorus preserving pancreatoduodenecotomy presenting with obstructive jaundice and ascending cholangitis. Clin Endosc. 2011; 44:59–64. PMID: 22741115.

7. Capaccio E, Zuccarino F, Gauglio C, Pretolesi F, Derchi LE. Acute obstruction of the afferent loop caused by an enterolith. Emerg Radiol. 2007; 13:201–203. PMID: 17109128.

8. Gale ME, Gerzof SG, Kiser LC, et al. CT appearance of afferent loop obstruction. AJR Am J Roentgenol. 1982; 138:1085–1088. PMID: 6979208.

9. Moriura S, Ikeda S, Kimura A, Iwatsuka Y, Ikezawa T, Naiki K. Jaundice due to afferent loop obstruction following hepatectomy for a hilar cholangiocarcinoma. Abdom Imaging. 1996; 21:226–227. PMID: 8661553.

10. Moriura S, Takayama Y, Nagata J, et al. Percutaneous bowel drainage for jaundice due to afferent loop obstruction following pancreatoduodenectomy: report of a case. Surg Today. 1999; 29:1098–1101. PMID: 10554338.

11. Burdick JS, Garza AA, Magee DJ, Dykes C, Jeyarajah R. Endoscopic management of afferent loop syndrome of malignant etiology. Gastrointest Endosc. 2002; 55:602–605. PMID: 11923786.

12. Bourke MJ, Schneider DM, Haber GB. Electrohydraulic lithotripsy of a gallstone causing gallstone ileus. Gastrointest Endosc. 1997; 45:521–523. PMID: 9199914.

13. Lee TH, Hwang JC, Choi HJ, et al. One-step transpapillary balloon dilation under cap-fitted endoscopy without a preceding sphincterotomy for the removal of bile duct stones in Billroth II gastrectomy. Gut Liver. 2012; 6:113–117. PMID: 22375180.