Sonographic diagnosis of afferent loop obstruction

A 55-year-old man had abdominal pain, weight loss and nausea 1 #{189} years after a Whipple operation for adenocarcinoma of the ampulla of Vater. The latter procedure consisted of a pancreaticoduodenectomy, subtotal gastrectomy, and retrocolic gastrojejunostomy with pancreaticoand choledochojejunostomies. The physical examination of the present admission revealed a left epigastic mass and an enlarged liver. Pertinent laboratory values on admission were: hematocrit, 19.7% (normal, 47% ± 7%); bilirubin, 0.4 mg/dI (normal, 0.2-i .2 mg/dl); and alkaline phosphatase, 835 mU/mi (normal, 30-1 1 5 mU/mI). An abdominal radiograph demonstrated a large midline soft-tissue mass displacing bowel loops inferiorly, which was indistinguishable from a very enlarged liver. A eamTc sulfur colloid liver-spleen scan showed multiple filling defects in an enlarged liver. Sonography of the abdomen was performed using a commercially available real-time sector scanner. Initial sagittal scans over the midportion of the epigastrium demonstrated a fluid-filled stomach and a second large fluid-filled structure containing echogenic debris (fig. 1 A). Subsequent oblique scans of the right upper quadrant demonstrated a dilated intrahepatic biliary tree. The common bile duct was traced into the fluid-filled structure (fig. 1B). In light of the patient’s surgical history, a diagnosis of afferent loop obstruction was made. A percutaneous transheptic cholangiogram the next day confirmed a dilated biliary tree with a patent choledochojejunostomy. Contrast material easily filled the markedly dilated loop of jejunum (fig 1 C). Upper gastrointestinal endoscopy could visualize only the efferent loop. Exploratory laparotomy confirmed the diagnosis of afferent loop obstruction. A large, hard tumor mass was palpated in the upper abdomen obstructing the afferent loop near the gastrojejunostomy stoma. A palliative side-to-side jejunojejunostomy, anastomosing the dilated afferent loop with a segment of nondilated efferent loop, was accomplished. Case 2